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Digitized  by  tine  Internet  Archive 

in  2010  with  funding  from 
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DENTAL   ORTHOPEDIA 

AND 
TREATMENT  OF  CLEFT   PALATE 


A  PRACTICAL  TREATISE 


ON  THE 


TECHNICS  AND   PRINCIPLES 


OF 


DENTAL  ORTHOPEDIA 


AND 


Prosthetic  Correction  of 
Cleft  Palate 

CALVIN    S.  CASL,  ]\L  D.,  D.D.S. 

Formerly,  Professor  of  Orthodontia.  Chicago  C'olle;^ge " of  Dental  Surgery.    Demonstrator  of  Prosthetic 
Dentistry,  Univ.  of  Mich.;  Professor  of,  Orthodontia,  W.  R;  U.;  and  Professor  of  Prosthetic  Den- 
tistry   AND    Orthodontia,  C.    C.    of    Dt    S.     Author    of  '"Facial    and    Oral    Deformitif.s"; 
"The    Development    of    Esthetic    Facial    Contovrs,"-   in    the   American   Textbook 
of  Operative  Dentistry,  etc.     Member  of  thb  International  Dental  and 
International  Medical  Associations,  National  Dental  Associa- 
tion, Illinois  State  Dental  Society;    Honorary  Member 
First  District  Dental  Society,  New  York  City; 
Honorary  Member  of  the  Odontological 
Society  of  New  York  City;  and 
Member  of  all  Chicago 
Dental  Societies 


CHICAGO 
PUBLISHED  BY  THE  C.  S.  CASE  COMPANY 

1921 


/  1f  / 


Copyright.  1921 

In  Great  Britain  and  All  Countries 

Subscribing  to  the 

1 1  ternational  Copyright  Convention  at  Berlin 


Copyright.  1921 
In  the  United  States  of  America 

By 
CALVIN  S.  CASE 


All  Riihh  Reserved 


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E.   R.    DONNELLEY   i   SONS   COMPANY.  PRINTERS 
CHICAGO 


To  my  friends  and  all 

who  are  interested  in  the  highest 

possibilities  of  Dental  Orthopedia^  and  the  most 

scientific  correction  of  Cleft  Palate^ 

this  book  is  respectfully 

dedicated 


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PREFACE  TO  SECOND  EDITION 


The  present  and  second  edition  of  tliis  work,  which  now  bases  malocclusion 
upon  the  dento-occlusal  classification,  has  reciviired  a  complete  rewriting  and 
readjustment  of  nearly  every  department. 

The  part  which  taught  the  "technic  preparation  of  stock  material  and  instru- 
ments," has  been  eliminated,  and  in  its  place  the  technic  construction  of  ap- 
pliances in  Part  V  has  been  greatly  enlarged. 

The  work  proper  now  starts  with  Etiology  of  Malocclusion,  with  partictdar 
reference  to  Heredity.  As  the  principles  of  heredity  are  founded  upon  and  pertain 
to  the  principal  laws  of  biology,  an  intelligent  understanding  of  the  foundation 
principles  of  biology  seems  imperative. 

The  work  is  not  intended  as  an  unabridged  treatise  upon  the  various  systems 
employed  for  the  correction  of  malocclusion,  but  it  is  one  that  is  especially  designed 
for  teaching  the  technics  and  practical  principles  of  correcting  dental  and  dento- 
facial  irregvilarities  in  colleges  where  thorough  training  is  desired.  It  will  also  be 
found  convenient  and  instructive  as  a  reference  book  in  practice. 

In  the  presentation  of  the  work,  an  endeavor  has  been  made  to  arrange  sys- 
tematically the  different  branches  in  the  sequence  that  would  develop  in  the  natural 
demands  of  training  and  practice.  It  commences  with  the  foundation  principles 
of  the  science,  and  carries  the  work  through  the  several  progressive  stages  to  the 
final  construction  and  adjustment  of  regulating  apparatus  and  retaining  appliances. 
It  deals  concisely  with  general  and  special  principles  relative  to  the  application  of 
force,  diagnosis,  classification,  causes,  treatment,  and  retention.  The  description 
of  specific  methods  of  treatment  commences  with  Practical  Treatment  of  Classified 
Dento-facial  Malocclusions  in  Part  VI,  with  a  view  to  a  co-ordinate  systematic 
arrangement  especially  useful  in  teaching,  and  also  useful  to  those  who  contemplate 
operations  in  orthodontia. 

An  important  feature  of  the  work  is  the  employment  of  the  half-tone  illus- 
trations of  cases  selected  from  the  author's  practice  to  illustrate  from  a  prac- 
tical standpoint  the  three  Classes  of  Dento-facial  Deformities  and  the  results  of 
correction. 

Lengthy  and  verbose  histories  of  cases,  with  a  detailed  account  of  the  successive 
methods  and  steps  that  were  pursued,  which  would  in  all  probability  never  be  the 
same,  even  in  two  apparently  similar  cases  by  the  same  operator,  will  not  be  found 
in  this  work.  The  time  will  be  far  more  profitably  spent  in  a  study  of  the  underlying 
principles  of  the  science  —  in  the  acquirement  of  the  peculiar  knowledge  that  is 

vii 


viii  PREFACE    TO  SECOND   EDITION 

essential  to  diagnosis  and  treatment,  and  in  gaining  an  intimate  knowledge  of  the 
principles  of  mechanical  forces  and  technic  methods  of  applying  them  to  a  single 
tooth,  so  as  to  move  it  in  every  possible  direction. 

Realizing  how  difficult  it  is  for  students  to  gain  a  clear  conception  of  some  of  the 
underlying  principles  of  this  branch  of  dentistry,  the  author  has  not  refrained  from 
repeating  many  times  throughout  the  work  the  same  ideas,  whenever  the  particu- 
lar subject  in  hand  has  seemed  to  demand  it.  This  will  be  found  especially  true 
in  regard  to  the  principles  of  occlusion  in  its  various  phases  and  relations  to  the  art 
of  correction  and  retention. 

On  account  of  the  large  number  of  irregularities  treated  in  this  work,  with 
nearly  every  malposition  that  is  common  to  the  teeth,  and  the  variety  of  forms  of 
the  appliances  applicable  for  their  correction,  the  system  will  doubtless  appear  to 
the  casual  observer  as  more  or  less  complicated.  But  if  one  carefully  considers  the 
proposition  here  presented,  i.  e.,  that  a  systematic  arrangement  and  classification  of 
every  distinctive  character  of  irregularity  will  enable  him  to  readily  and  surely  find 
in  the  illustrations  a  malposition  that  is  similar  to  the  one  which  he  wishes  to  treat, 
with  every  technic  instruction  for  the  construction  or  purchase  of  the  whole  or  any 
part  of  an  apparatvis  that  is  scientifically  applicable  for  its  correction,  he  will  never 
again  resort  to  other  methods  whose  greatest  recommendation  is  their  apparent 
simplicity. 

While  it  is  always  desirable  to  simplify  the  apparatus  and  methods  of  applying 
force  to  the  teeth,  the  attempt  to  use  certain  methods  or  appliances  solely  because  of 
their  apparent  simplicity,  which  may  be  inadequate  to  meet  the  special  require- 
ments of  the  case,  greatly  increases  the  difficulties  of  the  operation,  and  often  is  the 
sole  cause  of  failure.  In  fact,  simplicity  of  treatment,  ease  and  satisfaction  in  the 
adjustment  and  management  of  regulating  appliances,  and  comfort  to  the  patient, 
are  always  in  proportion  to  the  special  adaptability  and  adequacy  of  the  apparatus 
to  accomplish  the  work  successfully.  Even  this  would  fail  without  the  skill  of  an 
operator  capable  of  making  slight  but  important  variations  in  its  construction  or 
adjustments,  of  determining  when,  where,  and  how  to  apply  the  force,  and  espe- 
cially when  to  reduce  or  stop  it,  and  change  the  whole  or  parts  of  the  appliances  for 
methods  or  variations  that  more  fully  meet  the  demands  of  the  changed  and  chang- 
ing conditions. 

A  grateful  appreciation  is  most  heartily  acknowledged  for  the  aid  derived  from 
the  teachings  of  others  to  whom  honor  is  due  for  the  upbuilding  of  this  branch  of 
dentistry;  and  while  the  work  will  be  found  free  from  any  attempt  to  copy  the 
various  published  methods,  it  is  not  that  their  importance  is  undervalued,  or  that 
the  system  here  presented  is  not  largely  permeated  by  and  dependent,  in  many  of 
its  important  principles,  on  the  work  of  others,  but  principally  because  the  aim  has 
been  to  teach  only  that  which  has  been  practically  applied  in  the  author's  own 
practice.  Wherever  principles  and  methods  from  the  works  of  others  have  been 
employed  that  could  be  located  in  the  field  of  common  property  literature,  due 


PREFACE   TO  SECOND  EDITION  ix 

credit  is  given.  Dr.  Angle  has  truly  observed:  "To  fair  minds,  recorded  dates  are 
usually  sufficient  evidence  of  priority."  Unfortunately,  this  rule  has  not  always 
been  strictly  observed. 

Among  the  men  of  this  country  to  whom  the  author  is  particularly  indebted  for 
many  ideas  pertaining  to  the  practice  of  dental  orthopedia,  may  be  mentioned 
Drs.  Kingsley,  Farrar,  Angle,  Black,  Guilford,  Matteson,  Cryer,  Jackson,  and 
others.  The  author  is  especially  indebted  to  his  son,  Dr.  Carl  B.  Case,  for  many 
important  suggestions,  and  the  invention  and  improvement  of  numberless  ingenious 
and  effective  appliances,  instruments,  etc.,  and  also  for  valuable  aid  in  the  prepara- 
tion of  drawings  which  illustrate  this  work. 

An  important  addition  to  this  work  is  the  treatise  upon  the  Prosthetic  Correction 
of  Cleft  Palate.  It  is  a  branch  of  dentistry  which  most  perfectly  co-ordinates  with 
the  practice  of  orthodontia,  for  while  it  pertains  principally  to  the  correction  of 
speech,  the  correction  of  malposed  teeth  and  deformed  facial  outlines  frequently 
forms  the  most  important  and  indispensable  part  of  a  successful  cleft  palate  opera- 
tion. There  is  no  branch  of  dentistry  which  can  bring  more  pleasure,  satisfaction, 
and  grateful  appreciation,  than  the  correction  of  speech  for  cleft  palate  patients,  or 
one  which  is  founded  so  wholly  upon  scientific  principles  of  practice. 

C.  S.  C. 

Chicago,  1921. 


CONTENTS 


INTRODUCTORY   PREFACE 


PART  I 

PRELIMINARY  PRINCIPLES  OF   PRACTICE 

CHAPTER   1 
SCOPE   OF   DENTAL   ORTHOPEDIA 

PAGE 

An  Appeal  for  a  Higher  Education  and  Thorough  Training  in  those  Branches  of  Science,  Art, 

and  Mechanics  which  Pertain  to  this  Department 3 

CHAPTER   II 

NOMENCLATURE 

A  Resume  of  the  Tcmis  Employed  in  this  Work  and  Applicable  in  Dental  Orthopedia,  with  the 
Author's  Objections  to  the  Misapplication  of  Terms  of  Definite  Meanings,  and  the  Drop- 
ping of  Terms  of  Established  Usage  and  Scientific  Applicability  for  New  and  Odd  Terms, 
However  Ajjplicable 8 

CHAPTER   III 

DENTO-OCCLUSAL   CLASSIFICATION   OF   MALOCCLUSION 

Explains  Objects  of  a  Classification  —  Basis  of  Present  Classification  —  The  Disto-Mesial 
Occlusion  of  Buccal  Teeth  —  The  Three  Classes,  Normal,  Distal,  and  Mesial  —  Why 
Certain  Malocclusions  Arising  from  a  Local  Cause  Cannot  be  Classified — Classified  Chart 
of  Malocclusions 15 


PART  II 

ETIOLOGY  OF  MALOCCLUSION 

CHAPTER   IV 

ETIOLOGIC  PRINCIPLES  OF  MALOCCLUSION  WITH  REFERENCE  TO  TREATMENT 

Unknowable  Causes  — •  Compound  Causes  — ■  Relation  of  Causes  to  Treatment  —  Importance 

of  Correct  Diagnosis  —  Influences  of  Heredity 23 

xi 


xii  CONTENTS 

CHAPTER  V 

ETIOLOGIC  INFLUENCES  OF  DECIDUOUS  AND  ERUPTING  PERMANENT 
TEETH  WITH   PRINCIPLES  OF   TREATMENT 

Why  this  Stage  Is  the  Most  Prolific  of  the  Local  Causes  —  Maleruption  of  Labial  Teeth  — 
Importance  of  Preserving  the  Deciduous  Second  Molars  and  Cuspids  —  Thumb-Sucking  — 
Influences  of  Heredity  —  A  Local  Cause  of  Protrusion  —  Comparison  of  Childhood  and 
Adult  Physiognomies 30 

CHAPTER   \T 

LAWS   OF    BIOLOGY"    REGARDED   AS    ETIOLOGIC    FACTORS    IN    MALOCCLUSION 

General  Principles  of  Biology  —  Heredity  —  Natural  Variation  —  Natural  Selection  —  En- 
vironment       37 

CHAPTER  Vn 

HEREDITY  AND   VARIATION   ETHNOLOGICALLY   CONSIDERED 

General  Consideration  —  Adendcl's  Law  —  The  Possibility  of  Mendel's  Law  as  One  of  the 
Etiologic  Factors  in  Malocclusion  —  Men  of  the  Old  Stone  Age  —  Atavistic  Heredity 
and  Its  Possible  Influence  upon  Races  and  Present  Types  of  Physiognomies      ....     43 

CHAPTER  VHI 

PRACTICAL   APPLICATION    OF    BIOLOGIC   LAWS 

General   Influences  of  Heredity  —  Direct  —  Atavistic  —  Union  of   Disharmonious  Types  — 

Influences  of  Hereditv  in  Relation  to  Treatment 51 


PART  III 

BASIC   PRINCIPLES   OF   PRACTICE 

CHAPTER   IX 

ARRANGEMENT   OF    THE    TEETH    AND    ALVEOLAR    PROCESS 
ANATOMICALLY    CONSIDERED 

By  Dr.  G.  V.  Black 

Arrangement  of  the  Teeth  —  The  Alveolar  Process  and  Alveoli 61 

CHAPTER  X 

TYPICAL  AND  ATYPICAL  OCCLUSION   OF   THE   TEETH   IN    RELATION   TO 
THE  CORRECTION   OF   IRREGULARITIES 

By  Dr.  Matthew  H.  Cryer 

Shows  Absurdity  of  Regulating  Teeth  by  Rule  —  Typical  vs.  Actual  Anatomy  and  Occlusion 
—  Extraction  for  the  Correction  of  Irregularities  —  Characteristic  Features  of  Caucasian 
and  Negro  Skulls  —  Prognathous  Appearance  Caused  by  Hypertrophied  Gums  and 
Alveolar  Processes 68 


CONTENTS  xiii 

CHAPTER  XI 
DENTO-FACIAL   PRINCIPLES   OF  OCCLUSION  WITH   REFERENCE  TO  PRACTICE 

Occlusal  Relations  —  Importance  of  Striving  for  a  Normal  Occlusion,  but  not  at  the  Expense 
of  Producing  or  Leaving  a  Facial  Deformit}'  —  Importance  of  Angle's  Teaching  in  Com- 
parison with  that  of  the  Author  —  Why  a  Normal  Occlusion  should  not  be  Regarded  as 
a  Basis  of  Correction 78 

CHAPTER   Xn 

THE  QUESTION  OF  EXTRACTION  IN  ITS  RELATION  TO  CAUSES, 
DIAGNOSIS  AND  TREATMENT 

Rules  of  Extraction  —  Injudicious  Extraction  of  Permanent  Teeth  —  Judicious  or  Rational 

Extraction  of  Permanent  Teeth 83 


PART  IV 

TECHNIC   PRINCIPLES   OF   PIL^CTICE 

CHAPTER  XIII 

PRINCIPLES   OF   MECHANICS   IN   THE   MOVEMENT  OF   TEETH 

Inclination  Movement  —  Levers  —  Post  Levers  —  Tooth  Levers  —  Relations  of  Power,  Stress 
and  Movement  —  Relating  to  Bodily  Movement  —  Rotating  Movement  —  Intrusive  and 
Extrusive_Movements 95 

CHAPTER  XIV 
BODILY   MOVEMENTS 

Principles  of  Bodily  Movements  —  Always  through  the  Lever  Action  of  the  Third  Kind  — 

Torsional  Force  Applied  to  Bodily  Movements 109 

CHAPTER  XV 

PRINCIPLES   OF   DENTAL  ANCHORAGES 

Character  of  Force  Regulating  Immovability  —  Principles  of  Anchorage  Stability  —  Station- 
ary Anchorages  —  Root-wise  Anchorages  —  Sustained  Anchorages  —  Reciprocating  An- 
chorages   118 

CHAPTER  XM 
PRINCIPLES   OF   INTERMAXILLARY   AND   OCCIPITAL   FORCE 

Intennaxillary  Force  —  Occipital  Force 126 


xiv  CONTENTS 

PART  V 

PRIMARY    PR  I NXIPLES   OF    PRACTICE 

CHAPTER  XVII 

IMPRESSIONS   AND    CASTS 

Modeling-Compound  —  Dental  Casts  —  Facial  Impressions  and  Casts 139 

CHAPTER  XVIII 
PRIMARY    PRINCIPLES    AND    TECHNICS    IN    THE    CONSTRUCTION   OF   BANDS 

Separating  Teeth  —  Orthodontia  Bands  —  Soldering  Bands  —  Silver  Solder 147 

CHAPTER   XIX 

ADVANCED   PRINCIPLES   AND   TECHNICS   OF   REGULATING   BANDS 

Preliminary  Fitting  —  Relation  of  Coronal  Zones  —  Placing  Bands  —  Removal  of  Bands  — 
Soldering  Attachments  —  Management  of  Solder  and  Blowpipe  —  Bands  for  Midget 
Appliances  —  Finishing  and  Plating  —  Advantages  of  Nickel  Silver 155 

CHAPTER  XX 
MODERN    PRINCIPLES   AND   METHODS    IN   ORTHODONTIA 

Three  Characters  of  Malocclusion  in  One  Case  —  Midget  Apparattis  —  Bodily  Movement 
Apparatus  —  The  Technics  of  Attachments  —  Assembling  Apparatus,  and  Adjustment 
Treatments  —  Bodily  Working-Retainer 166 


PART  VI 

PRACTICAL    TREATMENT     OF     DENTO-FACIAL     MALOCCLUSIONS 

CHAPTER  XXI 

ORTHODONTIC  PRINCIPLES  OF  DIAGNOSIS  AND  GENERAL 
RULES   OF  TREATMENT 

Introduction — -Scope  of  the  Dento- Facial  Field  —  Dento-Facial  Area — -Zones  of  Move- 
ment —  Remarkable  Changes  in  Facial  Expression  with  Slight  Movements  —  Dento- 
Facial  Outlines  in  Diagnosis  —  Observation  Training  —  Practical  Diagnosis  —  Principles 
of  Diagnosis  According  to  Classes 181 

CLASS  I.     NORMAL  DISTO- MESIAL  OCCLUSION 

Table  of  Divisions  and  Types 199 


CONTENTS  XV 

CHAPTER  XXII 

PRINCIPLES   OF   DIAGNOSIS   IN   MALERUPTION   OF   THE   CUSPIDS 

Diagnosis  —  Practical  Application  of  Rules   .      .  ' 200 

CHAPTER  XXIII 
Type  A,  Division  1,  Class  I.     UNILATERAL   MALERUPTION  OF  THE   CUSPIDS 

Full  DescriiJtion  with  AiJjiaratus  for  the  Treatment  of  Siniijle  and  Complicated  Cases       .      .   205 

CHAPTER  XXIV 

Type  B,  Division  1,  Class  I.     BILATERAL     MALERUPTION    OF    CUSPIDS    COR- 
RECTED WITHOUT   EXTRACTION 

Full  Description  with  Apparatus  for  the  Treatment  of  Simple  and  Complicated  Cas3s  .      .      .   209 

CHAPTER  XXV 

Type  C,  Division  1,  Class  I.     BILATERAL  MALERUPTION    OF  UPPER  CUSPIDS, 

REQUIRING   EXTRACTION 

Differential  Diagnosis  and  Treatment 215 

CHAPTER  XXVI 

Type  D,  Division  1,  Class  I.     THUMB-SUCKING    PROTRUSION  OF   THE  UPPER 

FRONT  TEETH 218 

CHAPTER   XX\  II 

Type  F,  Division   1,  Class  I.     LATERAL  MALOCCLUSION 

First  Fonn  —  Second  Form 220 

CHAPTER  XXVIII 

Type  G,  Division   1,  Class   I.     OPEN-BITE   AIALOCCLUSION 

Diagnosis  —  Causes  —  Treatment 227 

CHAPTER  XXIX 
Division  2,  Class  I.     BIMAXILLARY  PROTRUSION  AND  RETRUSION 
Diagnosis  —  Causes  —  Treatment 232 

CLASS  II.     DISTAL  MALOCCLUSION  OF  LOWER  BUCCAL  TEETH 
Table  of  Divisions  and  Types 245 


xvi  CONTENTS 

CHAPTER  XXX 
INTRODUCTION    TO   CLASS    II 246 

CHAPTER  XXXI 

Type  A,  Division  1,  Class  II.     PRONOUNCED     RETRUSION     OF     THE     LOWER 

DENTURE  WITH  UPPER  NORXIAL 

Principles  of  Diagnosis,  Treatment,  and  Retention 249 

CHAPTER   XXXII 

Type  B,  Division  I,  Class  II.     MODERATE    RE^fRUSION  OF   THE   LOWER    DEN- 

1  URl-:,  AND  PARTIAL  PROTRUSION  OF  THE  UPPER 

Diagnosis  and  Treatment  —  Intermaxillary  Force 255 

CHAPTER   XXXI 11 

Division  2,  Class  1 1.     INTRODUCTION 259 

CHAPTER  XXXIV 

Type  A,  Division  2,  Class  II.     UPPER   CORONAL   PROTRUSION 262 

CHAPTER  XXXV 

Type  B,  Division  2,  Class  II.     UPPER   BODILY   PROTRUSION 266 

CHAPTER  XXXVI 

Type  C,  Division  2,  Class  II.     UPPER    CORONAL    PROTRUSION    WITH    APICAL 

RETRUSION 270 

CHAPTER  XXXVII 

Type  D,  Division  2,  Class  II.     UPPER   APICAL    PROTRUSION 274 

CONCOMITANT  CHARACTERS  OF  CLASS  II 

CHAPTER  XXXVIII 

RETRUSION   OF   THE   MANDIBLE   AND    LOWER    DENTURE  279 

CHAPTER  XXXIX 

CLOSE-BITE   MALOCCLUSION ....  283 

CLASS  III.     MESIAL  MALOCCLUSION  OF  LOWER  BUCCAL  TEETH 
Table  of  Divisions 290 


COXTENTS  xvii 

CHAPTER  XL 
PRINCIPLES   OF   DIAGNOSIS,   CAUSES,   AND  TREATMENT 291 

CHAPTER   XLI 

Division    1,     Class    III.     BODILY     RETRUSION     OF     THE     UPPER     DENTURE 

AND   MAXILLA 295 

CHAPTER   XLU 
THE  PROTRUDING   CONTOUR  APPARATUS 298 

CHAPTER   XLHI 

Division     2,     Class   HI.     CONTRACTED       RETRUSION       OF        THE        UPPER 

DENTURE 301 

CHAPTER  XLIV 

Division    3,     Class    HI.      UPPER       RETRUSION       WITH        PROTRUSION        OF 

LOWER    DENTURE 312 

CHAPTER  XLV 

Division  4,  Class  HI.  RETRUSION  OF  THE  UPPER  DENTURE  WITH  PROG- 
NATHIC MANDIBLE  COMMONLY  ACCOMPANIED 
WITH  OPEN-BITE  MALOCCLUSION 317 


PART  VII 

PRACTICAL  TREATMENT  OF  UNCLASSIFIED  MALOCCLUSIONS 
Table  of  Characters •    .   328 

UNCLASSIFIED  MALPOSITIONS 
Foreword 329 

CHAPTER   XLM 

INFRA   AND   SUPRA-OCCLUSION 

Infra-Occlusion  of  Cuspids  —  Infra-Occlusion  of  LTjipcr  Incisors 331 

CHAPTER  XL\  II 
CROWDED   MALALIGNMENTS 333 

CHAPTER   XIA'IIT 
MALTURNED   TEETH 339 


xviii  CONTENTS 

CHAPTER   XLIX 
NARROW  AND   WIDE   ARCHES 346 

CHAPTER   L 
ABNORMAL   INTERPROXIMATE   SPACES 354 

CHAPTER   LI 
IMPACTED  TEETH   AND  THEIR  TREATMENT 362 


PART  VIII 

PRINCIPLES  AND  TECHNICS   OF   RETENTION 

CHAPTER   LI  I 

PRINCIPLES   OF   RETENTION 

Influences  of  Heredity  —  Local  Influences  —  Occlusal  Influences  —  Importance  of  Interdigita- 
tion  of  Cusps  —  Importance  of  Extraction  —  Importance  of  Bodily  Movement  —  Sum- 
mary of  Principles  —  Imperative  Demands  of  Retaining  Fixtures 377 

CHAPTER   LIII 

LABIAL   RETAINING    FIXTURES 

Quality  and  Technics  of  Bands  —  Technics  of  Construction  —  Six-Band  Labial  Retainer  — 
Details  of  Construction  —  Placing  the  Appliance  —  Removal  of  the  Appliance  —  Re- 
storing Broken  Extensions 384 

CHAPTER   LIV 

SUPPLEMENTARY   RETAINING   ATTACHMENTS   AND   APPLIANCES 

Retention  of  Lateral  Expansions  —  Retention  of  Rctruded  Movements  —  Intermaxillary  Re- 
tention —  Reciprocal  Retaining  Action  —  Direct  Intermaxillary  Retention  — ■  Occipital 
Retention  —  Retention  of  Bodily  Movements  —  Permanent  Retaining  Fixtures   .      .      .   393 


PART  IX 

THE   PROSTHETIC   CORRECTION   OF   CLEFT   PALATE 

CHAPTER   I 

GENERAL  PRINCIPLES  IN  THE  MECHANISM  OF  SPEECH,  AND  THE  TRAINING 
OF    CLEFT   PALATE    PATIENTS   AFTER   OPERATIONS 

Importance  of  Proper  Instruction  —  Practical  Teaching  —  Sound-Images  —  Practical  Appli- 
cation of  Methods  of  Instruction 409 


COXTEXTS  xix 

CHAPTER   II 
PHYSIOLOGIC  AND   PHONETIC   PRINCIPLES   IN   THE   ART  OF   SPEAKING 

Mechanism  of  Speech  —  The  Vehim-Palati  —  Resonance  —  The  Oral  Elements  of  Vowels  and 
Consonants  —  The  Vowels  —  The  Consonants  —  The  Intrinsic  Value  of  Illustrations  — • 
Classification  of  Consonant  Oral  Elements  —  The  Nasals  —  The  Explosives  — ■  The 
Aspirates  —  The  Open  Aspirates  —  The  Explosive  Aspirates  —  Relative  to  the  Chart    .   420 

CHAPTER   III 

THE   TECHNIC   CONSTRUCTION   OF  THE   VELUM-OBTURATOR 

The  Impression  and  Alodcl  of  the  Cleft  —  Small  Clefts  —  Two-Section  Impression  —  Three- 
Section  Impression  —  Plaster  Working-Model  of  the  Cleft 437 

CHAPTER   IV 

THE   TRIAL   MODEL   OF   THE   OBTURATOR 

The  Body  of  the  Obturator-Model  —  The  Veil  of  the  Obturator-Model  —  The  Most  Scien- 
tific Part  of  the  Operation 450 

CHAPTER  V 
THE    LABORATORY    TECHNIC    CONSTRUCTION    OF    THE    OBTURATOR-MODEL 

Preparation  of  the  Plaster  Model  —  The  Flask  —  Preliminary  Principles  —  The  First  Set  of 

Plaster  Models  —  Plaster  and  Investment  Models  —  Investment  Models 456 

CHAPTER  \T 
TECHNICS   OF  THE   METAL   CASTS  AND   OBTURATOR 
Metal  Casts  of  the  Models  A,  B,  and  C  —  Preparatory  to  Packing  and  Finishing  the  Obturator  466 

CHAPTER   VII 

COMPLICATIONS   WITH   IRREGULARITIES   AND   SURGICAL   FAILURES      .      .  471 


PART  I 


Preliminary  Principles  of  Practice 


DENTAL  ORTHOPEDIA 


CHAPTER   I 

SCOPE   OF   DENTAL   ORTHOPEDIA 

Dental  Orthopedia,  more  commonly  designated  Orthodontia,  or  Orthodontics, 
is  the  science  which  has  for  its  object  the  correction  of  dental  and  dento-facial 
malocclusion.  The  term  Malocclusion  in  its  present  broad  acceptance,  not  only 
applies  to  every  form  of  dental  irregularity,  but  to  all  imperfections  in  facial  out- 
lines that  are  caused  from  malpositions  of  the  teeth  and  jaws,  or  that  may  be 
corrected  through  the  medium  of  mechanically  constructed  appliances  attached 
to  the  teeth. 

In  commencing  the  study  of  orthodontia,  a  preliminary  knowledge  of  the 
elementary  and  general  basic  principles  is  imperative.  The  student  should  first 
become  conversant  with  the  nomenclature  of  orthodontia  (Chapter  II),  and  the 
classification  of  malocclusion  (Chapter  III),  in  order  that  he  may  have  a  clear  and 
immediate  understanding  of  the  exact  meaning  of  the  technical  terms  employed, 
and  the  general  characters  of  Classes  and  Divisions  of  Malocclusion.  This  will 
enable  him  to  start  with  an  intelligent  understanding  of  the  work  from  the  very 
beginning,  and  thus  he  will  be  able  to  fully  grasp  and  think  out  for  himself  each  one 
of  the  steps  as  he  progresses. 

As  the  science  relates  to  the  correction  of  malocclusion  for  the  promotion  of 
normal  functions,  esthetic  relations,  and  the  beautifying  of  facial  outlines,  it  will  be 
seen  that  it  pertains  to  physical  changes  in  the  structure  and  position  of  important 
parts  of  the  human  body  which  we  have  no  right  to  touch  except  with  proficient 
knowledge  of  subjects  which  pertain  to  causes,  diagnosis,  and  treatment.  As  the 
treatment  consists  principally  in  the  application  of  force  appliances  to  the  teeth, 
and  is  dependent  largely  upon  a  knowledge  of  mechanics  and  art,  it  is  important 
that  the  student  should  lay  a  broad  and  firm  foundation  through  the  acquirement 
of  all  branches  which  pertain  to  this  subject,  and  then  with  a  knowledge  of  the  va- 
rious causes  of  malocclusion,  and  an  understanding  of  the  true  principles  of  diag- 
nosis, he  will  more  fully  appreciate  what  it  is  that  established  the  standard  of 
correction,  and  why  it  is  necessary,  desirable,  and  possible. 

Let  us  briefly  consider  the  present  status  of  dental  and  dento-facial  orthopedia, 
and  the  character  and  scope  of  the  requirements  which  are  necessary  to  the  highest 
standard  of  its  attainment.  To  sense  all  that  is  implied  by  dental  and  dento-facial 
malocclusion,  one  must  know  what  is  implied  by  the  normal,  the  ideal,  and  the 

3 


4  PART  I.     I'RELIMISARV    PR/XCIPLES  OF   PRACTICE 

esthetic,  relative  to  this  branch  of  dentistry,  and  to  reahze  that  the  growth  and 
development  of  dental  orthopedia  has  carried  it  beyond  the  mere  mechanical 
correction  of  irregularities  of  the  teeth,  their  malrelations  to  each  other  and  to 
occlusion,  and  has  placed  it  in  a  position  where  facial  art  is  one  of  the  indispensable 
bases  of  treatment.  In  nature's  laboratory,  things  rarely  occur  mathematically, 
mechanically,  or  ideally  perfect  in  all  their  parts.  This  is  attested  by  every  organ 
and  part  of  the  human  body.  If  opticians  should  copy  exactly  the  lines  and  re- 
fractibility  of  a  normal  natural  lens,  they  would  fall  far  short  of  the  mathematical 
requirements  of  an  artificial  lens. 

Some  orthodontic  authors  wishing  to  visually  illustrate  by  an  anatomic  specimen 
what  they  have  most  beautifully  and  ideally  described  as  a  "normal  occlusion" 
are  confronted  with  the  almost  impossible  object  of  their  search,  because  they  seek 
for  a  specimen  of  ideal  rather  than  normal  or  anatomic  occlusion;  whereas,  any 
quantity  of  normal  occlusion  of  the  teeth  could  be  found  everywhere. 

The  apparently  frantic  efforts  of  authors  along  this  line  have  led  them  to 
accept  certain  specimens  for  their  illustrations,  quite  regardless  of  the  race,  or 
incongruity  of  the  facial  outlines  of  the  living  individual  to  whom  the  specimen 
belonged.  See  Cryer,  Chapter  X.  As  one  becomes  more  fully  informed  in  regard 
to  the  science  of  orthodontia,  he  will  more  deeply  appreciate  the  fact  that  its  highest 
attainment  is  harmony  in  dental  and  dento-facial  relations,  for  use,  health,  develop- 
ment, and  beauty.  As  by  far  the  largest  proportion  of  dentures  require  to  be  placed 
in  normal  occlusion  in  order  to  fulfill  the  desired  perfection  of  facial  outlines,  a 
study  of  normal  occlusion  lies  at  the  very  foundation  of  orthodontic  requirements. 

The  student  is  urgently  referred  to  Dr.  Angle's  perfect  description  of  an  "ideal 
normal  occlusion"  under  the  heading  "Occlusion"  in  his  work  entitled  "Mal- 
occlusion of  the  Teeth."  In  connection  with  this,  the  chapters  in  this  work  entitled 
"Arrangement  of  the  Teeth  and  Alveolar  Process  Anatomically  Considered," 
by  Black;  "Typical  and  Atypical  Occlusion  of  the  Teeth  in  Relation  to  the  Cor- 
rection of  Irregularities,"  by  Cryer;  and  "Principles  of  Occlusion  and  Dento- 
Facial  Relations,"  by  the  author,  will  be  found  replete  in  everything  of  practical 
value  which  relates  to  occlusion  of  the  dentures,  and  its  iinportance  and  rightful 
place  in  dental  orthopedia. 

The  advancement  of  dental  orthopedia  to  a  gradually  increasing  position  of 
permanency  and  reliability  has  undoubtedly  been  accomplished  through  the  natural 
evolution  toward  a  higher  order  of  attainments  and  skill,  stimulated  no  doubt  by 
cei'tain  teachers  who  possessed  special  qualifications.  There  is  probably  no  depart- 
ment of  dentistry  in  which  the  relative  branches  of  applied  science  and  art  are  so 
indispensable  to  its  highest  success,  or  one,  moreover,  in  which  training  in  advanced 
principles  of  mechanics  is  so  important.  It,  therefore,  becomes  necessary  in  the 
teaching  of  this  department  to  dwell  more  or  less  upon  these  basic  principles,  to 
aid  the  student  in  laying  the  proper  foundation  for  practice,  with  the  hope  also  that 
it  will  stimulate  him  to  a  thorough  equipment  in  the  future  that  will  fully  prepare 


CHAPTER   I.     SCOPE  OF   DENTAL   ORTHOPEDIA  5 

him  for  high  professional  attainments,  whether  or  not  he  decides  to  practice  this 
branch  as  a  speciahy. 

In  the  present  broad  scope  of  advancement  in  orthodontia,  or  dental  and  dento- 
facial  orthopedia,  the  science  demands  for  its  highest  attainment  an  intimate 
knowledge  of  all  relative  branches  of  applied  science,  art,  and  mechanics. 

Science. — One  should  know  the  anatomy,  histology,  physiology,  and  pathology 
of  the  teeth  and  all  associate  parts  which  enter  into  the  formation  of  the  oral,  nasal, 
and  naso-pharyngeal  cavities,  the  bones,  their  embryologic  and  post-natal  develop- 
ment, structure,  and  functions;  the  muscles,  their  physiologic  activities  in  mastica- 
tion, in  speech,  and  in  controlling  or  marring  the  normal  development  and  form  of 
the  dental  arches.  He  should  be  capable  of  immediately  recognizing  local  patho- 
logic conditions  which  interfere  or  inhibit  normal  development,  and  which  fre- 
quently demand  the  services  of  other  specialists. 

In  the  biologic  field  will  be  found  much  of  interest  and  practical  instruction  to 
orthodontists,  especially  in  principles  of  heredity  and  natural  variation  which 
pertain  to  causes,  and  in  ethnology  which  relates  to  the  origin  and  development 
of  races  of  peoples,  with  their  characteristic  types  of  physiognomies.  This  is 
especially  important  inasmuch  as  it  is  thoroughly  proven  that  through  the  admix- 
ture of  dissimilar  racial  types,  and  types  of  the  same  race  that  are  quite  dissimilar 
in  sizes  and  physical  characters,  that  many  of  the  individual  disharmonies  and 
dento-facial  irregularities  of  our  own  race  have  arisen.  There  is  probably  no 
branch  of  science,  from  an  educational  and  practical  standpoint,  that  is  so  impor- 
tant to  orthodontists,  and  in  fact  all  men  of  the  medical  and  dental  profession,  as 
the  principles  of  biology,  because  biology  is  a  science  which  is  founded  upon  thor- 
oughly proven  investigations  that  are  accepted  as  true  by  all  learned  minds,  and 
because  it  relates  to  the  origin,  development,  evolution,  and  continued  co-ordina- 
tion of  all  living  things,  it  has  much  to  do  with  the  interests,  the  pleasures,  and  the 
practical  benefits  of  our  everyday  lives.  It  lies  at  the  very  foundation  of  nearly  all 
the  scientific  branches  which  we  regard  as  imperative  to  teach  in  our  dental  col- 
leges, and  it  is  especially  important  to  orthodontists,  because  it  shows  them  the 
true  etiologic  origin  of  many  of  the  dento-facial  malocclusions  they  are  called  upon 
to  treat ;  and  in  so  doing,  it  guides  them  toward  their  true  correction. 

It  would  seem,  however,  from  the  many  unreliable  statements  that  have  been 
made  within  the  past  few  years  by  some  of  the  men  who  stand  high  in  our  specialty, 
that  our  education  as  a  class  in  the  principles  and  truths  of  biology  had  been  sadly 
neglected.  And  because  these  statements  strike  at  the  very  root  of  important 
principles  in  our  advancement,  it  has  seemed  necessary,  in  order  to  effectually 
combat  them,  to  give  far  more  space  in  the  etiologic  branch  of  this  work,  to  the 
laws  and  principles  which  govern  these  important  questions,  than  would  other- 
wise be  necessary. 

Art. — From  the  first  activities  of  the  senses,  the  mind  intuitively  commences 
to  be  educated  and  early  accjuires  a  rudimentary  conception  of  relations  in  qualities, 


6  FART  J.     PRELIMIXARV   1'RI.\LIFLES  OF   J'RACFICE 

forms,  sizes,  distances,  colors,  etc.  As  the  mind  becomes  more  educated  solely 
throuj^h  these  repeated  contacts  of  the  senses  with  physical  things  and  natural 
phenomena,  there  arises  involuntarily,  and  without  our  seeking  or  realizing  why,  a 
pleasurable  appreciation  of  the  regular,  the  beavitiful,  and  the  harmonious,  in  the 
blending  of  colors,  the  rhythmic  union  of  musical  tones,  the  combination  of  graceful 
lines,  etc.,  until  subconsciously  we  know  without  being  told  when  a  perceptible 
disharmony  arises  which  we  are  almost  sure  to  intuitively  feel  in  proportion  to  its 
degree. 

In  no  branch  of  dentistry  does  there  arise  the  need  of  so  much  artistic  ability 
as  in  the  department  of  dento-facial  orthopedia.  One  who  possesses  the  true 
artistic  temperament  will  more  quickly  discern,  as  if  by  intuition,  esthetic  imper- 
fections in  dento-facial  outlines,  and  will  be  able  to  determine  in  advance  the  direc- 
tion and  amount  of  the  various  possible  movements  of  the  teeth  and  bony  frame- 
work required  for  correction. 

Those  who  fail  to  appreciate,  or  are  so  constituted  they  cannot  comprehend 
the  importance  of  this  particular  branch  of  applied  art  in  the  diagnosis  and  treat- 
ment of  dento-facial  imperfections  and  deformities,  will  never  know  the  satisfaction 
of  true  success  which  comes  to  him  who  reaches  the  higher  planes  of  this  specialty. 

But  let  no  earnest  seeker  after  these  high  attainments  in  dento-facial  art 
become  discouraged  by  the  many  mystifications  which  will  arise  in  the  minds  of 
students  and  in  practice,  providing  he  rises  to  a  realization  of  his  failures,  and  per- 
sists in  an  earnest  faithful  endeavor  to  master  the  principles  which  are  so  thoroughly 
taught  in  this  and  other  works  on  dental  orthopedia.  In  other  words,  the  faculty 
of  intuitive  artistic  discernment  in  diagnosis,  while  doubly  valuable  to  the  possessor 
may  be  duplicated  to  a  very  large  extent  by  observation,  training,  good  judgment, 
and  experience,  with  careful  and  intelligent  study  of  the  conditions  which  arise  in 
practice. 

Mechanics. — It  is  not  so  very  many  years  ago  that  dentists  who  aspired  to  high 
professional  standing  considered  it  somewhat  beneath  their  dignity  to  acknowledge 
that  the  highest  achievements  of  their  practice  depended  upon  their  mechanical 
ability.  Today,  it  is  freely  accepted  that  nearly  every  department  of  dentistry  is 
dependent  for  true  success  upon  the  art  of  mechanical  manipulation  and  prin- 
ciples of  mechanics.  Throughout  the  entire  universe  from  the  greatest  to  the  small- 
est, we  see  how  everything  is  developed  and  guided  by  mechanical  forces.  In  the 
biologic  field  we  find  in  every  living  thing,  for  its  protection  and  development,  a 
wonderful  display  of  mechanical  ingenuity  for  the  propagation  and  stimulation  to 
action,  in  all  histologic  and  anatomic  forms  and  structures,  from  the  simple  cell 
to  the  most  heterogeneous  organism. 

Consider  the  jaws,  their  structure,  physical  forms  and  relation  to  each  other  and 
to  other  parts  and  auxiliary  organs,  how  exactly  and  mechanically  in  accord  with 
their  use  and  functions  in  the  arrangement,  strength,  and  attachments  of  the  mus- 
cles to  produce  the  required  movements  and  forces;  in  the  form  and  structure  of 


CHAPTER  I.    SCOPE  OF   DENTAL  ORTHOPEDIA  7 

the  component  parts  of  the  teeth  and  alveolar  processes  to  resist  the  stresses  of 
mastication  without  injury  or  discomfort;  in  the  form  and  structure  of  the  enamel, 
the  cusps,  their  interdigitation  and  interdependence  in  occlusion  to  sustain  the 
forces  and  produce  the  most  perfect  trituration  of  foods;  in  everything  everywhere 
we  see  that  same  wonderfully  mechanical  ingenuity  employed  for  the  protection, 
preservation,  and  action  of  the  several  parts  according  to  their  needs  and  the  physi- 
cal activities  of  their  normal  functions.  One  has  but  to  become  thoroughly  ac- 
quainted with  the  activities  of  primary  and  secondary  dentition  to  be  filled  with 
wonder  and  admiration  at  nature's  mechanical  expedients  for  the  development, 
eruption,  and  arrangement  of  the  teeth. 

In  no  department  of  dentistry  is  there  so  great  an  opportunity  and  need  for 
mechanical  ingenviity  and  skill  based  upon  the  laws  of  mechanics,  as  in  orthodontia. 
The  reasons  for  this  are,  first,  no  two  cases  of  malocclusion  are  exactly  alike,  they 
having  variations  which  frequently  demand  individual  inventive  capacity  for  which 
no  guiding  rules  can  be  found.  Two  cases  which  seem  to  be  similar  and  are  alike  in 
occlusion  and  relations  of  dentures  to  each  other,  are  frequently  found,  by  an 
intelligent  diagnosis  of  facial  relations  to  be  widely  different  in  their  demands  of 
treatment,  and  in  the  application  of  forces.  Second,  the  correction  of  malocclusions 
does  not  consist  as  formerly  in  merely  pulling  and  pushing  the  crowns  into  align- 
ment and  occlusion,  but  one  of  its  most  common  demands  is  a  bodily  movement  in 
order  to  place  the  teeth  in  positions  of  greatest  usefulness  and  beauty,  and,  more- 
over, to  apply  the  forces  in  such  a  manner  that  the  dental  and  alveolar  arches,  and 
the  yielding  developing  jaws  will  take  their  proper  relations  to  each  other  and  to 
the  facial  outlines.  Third,  the  limited  opportunity  for  applying  the  various  forces 
through  the  medium  of  attachments  soldered  to  thin  bands  cemented  to  the  crowns 
of  teeth,  requires  a  thorough  knowledge  of  the  laws  of  applied  forces  which  relate 
to  this  department,  with  ingenuity  to  determine  the  most  eft'ective  methods  and 
skill  to  carry  forward  the  movements  according  to  the  required  mechanical  and 
physiologic  demands. 

This  branch  is  of  such  very  great  importance  to  a  successful  practice  of  dental 
orthopedia,  the  author  has  devoted  much  space  to  the  scientific  principles  of 
applied  mechanics,  which  relate  to  the  movement  of  teeth,  and  also  to  practical 
details  in  the  construction  and  application  of  appliances  and  apparatus  for  the  cor- 
rection of  all  the  common  forms  of  malocclusion,  fully  explaining  various  forces 
which  are  exerted,  and  the  probable  movements  of  the  teeth  that  are  produced. 
This  will  give  to  the  student  a  mental  training  which,  supplemented  with  the  manvial 
training  of  the  technic  department,  should  thoroughly  prepare  him  for  an  intelligent 
understanding  of  the  more  advanced  didactic  teaching  and  duties  of  infirmary  and 
final  office  practice. 


CHAPTER   II 

NOMENCLATURE 

A  correct  use  of  terms  that  may  be  universally  adopted  is  greatly  to  be  desired 
in  this  department  of  dentistry.  At  present  we  are  hampered  by  the  use  of  wrong  or 
ill-chosen  terms  which  we  are  unable  to  discard,  because  of  general  established  usage. 
Unfortunately,  there  has  been  an  effort  to  force  into  our  nomenclature  an  enlarged 
and  changed  definition  of  words  which  are  not  compatible  with  their  dictionary 
meaning  or  common  use.  Again,  the  effort  to  force  us  to  accept  terms  whose  root 
meanings  are  not  at  all  like  the  words  they  are  intended  to  represent,  is  very  bad 
form,  and  should  be  stopped  in  our  textbooks  and  teachings  before  these  misnomers 
become  too  thoroughly  established.  We  are  unhappily  mystified  also  by  the  use  of 
terms  which  prominent  writers  have  from  time  to  time  adopted  in  their  efforts  to 
find  words  that  would  more  clearly  and  concisely  express  their  meaning,  and  perhaps 
also  to  simplify  that  which  should  be  more  specifically  and  scientifically  defined. 

But  when  these  new  terms  are  odd.  and  unfamiliar,  whatever  their  scientific 
applicability,  they  should  not  be  forced  into  our  nomenclature  to  take  the  place  of 
other  terms  of  anglicized  established  usage  which  have  an  eqvial  claim  to  derivative 
applicability.  An  established  nomenclature  in  orthodontia,  or  any  branch  of 
scieiice,  is  not  a  thing  that  can  be  molded  like  putty  and  changed  in  form  by  any 
one  man,  or  by  chosen  "committees  on  nomenclature,"  and  especially  not,  if  they 
attempt  to  enlarge  or  restrict  the  definition  of  words  of  exact  meaning,  purely  by 
fiat,  or  to  discard  scientifically  coiTcct  terms  for  others  whose  roots  render  them 
inapplicable.  In  fact  it  is  next  to  an  impossibility  to  discard  the  employment  of 
established  terms  which  in  the  first  place  were  wrongly  chosen  as  regards  the  real 
meaning  of  their  roots,  even  though  other  terms  are  offered  in  their  place  that  are 
absolutely  correct  and  far  more  applicable. 

This  is  well  illustrated  in  the  selection  of  the  word  "Orthodontia"  as  the  title 
of  that  branch  of  dentistry  which  has  for  its  object  the  correction  of  malocclusion, 
or  irregular  teeth.  Its  choice  was  unfortunate,  becatxse  the  word  means  in  the 
Greek  "straight  tooth."  We  do  not  straighten  or  correct  the  shape  of  an  individual 
tooth  as  the  orthopedic  surgeon  corrects  the  form  and  shape  of  a  child,  but  we  cor- 
rect its  position  in  relation  to  surrounding  parts.  The  choice,  however,  was  ex- 
cusable as  long  as  the  art  was  confined  to  the  correction  of  dental  arch  alignment 
and  occlusion;  but  now  that  one  of  the  principal  accomplishments  of  the  art  is  to 
correct  facial  deformities  through  the  medium  of  force  applied  to  the  teeth,  the 
term  Dental  and  Dento-Facial  Orthopedia  is  far  preferable,  and  is  quite  univer- 
sally employed  in  other  languages,  but  the  long  established  use  of  the  term  "ortho- 

8 


CHAPTER   II.     NOMENCLATURE  9 

dontia"  in  this  country  has  doubtless  made  it  a  permanent  fixture.  It  is,  therefore, 
freely  used  in  this  work  in  its  restricted  sense. 

The  word  "Orthopedia"  is  derived  from  two  Greek  wordS' which  literally  trans- 
lated mean  "straight  child."  Originally,  the  word  was  chosen  to  indicate  that 
branch  of  general  surgery  which  has  for  its  object  the  straightening  or  correcting 
deformities  of  children  by  the  moderate  application  of  force  to  the  yielding  and 
developing- bones.  Orthopedic  surgery  in  its  present  and  broader  sense  includes  the 
correction  of  all  deformities  accomplished  in  a  similar  manner.  "Orthopedic 
Dentistry,"  or"Dental  Orthopedia,"  therefore,  would  plainly  specialize  the  art 
to  the  correction  of  all  dental  and  facial  deformities  accomplished  by  orthopedic 
movements  of  the  teeth  and  connecting  bones. 

The  following  terms  as  defined  will  be  used  in  this  work  as  the  standard  ex- 
pressions in  this  department  of  dentistry. 

Dento-Facial  Area  is  the  facial  area  which  is  supported  and  characterized  by 
the  teeth  and  the  alveolar  process. 

Dento-Facial  Relation  refers  to  the  relation  which  the  teeth  in  masticating 
occlusion  bear  to  the  physiognomy.  In  normal  dento-facial  relations,  or  dento- 
facial  harmony  the  teeth  and  overlying  features  are  in  the  most  perfect  harmony 
to  the  general  facial  outlines,  according  to  the  type  of  the  individual. 

Naso-Labial  Folds,  Depressions,  or  Lines,  extend  from  the  lateral  borders  of 
the  wings  of  the  nose  diagonally  downward  to  a  point  slightly  below  the  comers 
of  the  mouth,  marked  by  the  action  of  the  orbicularis  oris  and  risorius  muscles. 

Labio-Mental  Curve  or  Depression  is  the  concave  depression  beneath  the  lower 
lip  and  above  the  chin. 

Occlusion. — -The  term  "occlusion"  will  be  employed  in  this  work  to  mean  the 
same  as  defined  in  every  dictionary.  It  is  a  word  of  long  established  and  miwaver- 
ing  usage,  and  refers  anatomically  only  to  the  action  of  parts  or  organs  of  the  body 
whose  function  is  to  open  and  close.  When  the  lips,  the  eyelids,  or  the  teeth  are 
brought  temporarily  together  in  the  full  performance  of  their  immediate  functions, 
they  are  in  "occkision."  We,  therefore,  have  no  right  to  take  a  word  of  such  de- 
finite and  established  anatomic  meaning,  and  assert  purely  by  fiat  that  it  must 
henceforth  be  used  to  mean  "normal  occlusion,"  or  that  "normal  occlusion"  means 
"dento-facial  harmony."  In  orthodontia,  the  term  occlusion  refers  to  the  closure 
of  the  teeth  or  dentures  one  upon  the  other.  When  the  jaws  are  closed,  the  teeth 
that  fully  touch  each  other  are  in  "occlusion."  If  the  teeth  are  irregular,  but  with 
buccal  cusps  striking  well  into  closely  fitted  sulci,  they  are  in  "masticating  occlu- 
sion," though  they  may  not  be  in  normal  interdigitation.  If  no  teeth  are  missing, 
and  the  dentures  are  not  irregular  and  close  according  to  the  anatomic  standard, 
they  are  in  "normal,  or  anatomic  occlusion." 

The  terms  Normal,  and  Anatomic,  mean  "according  to  rule,"  or  "in  conformity 
to  natural  law."  In  orthodontia  they  are  useful  words,  because  slight  variations 
from  the  typical  are  the  rule  rather  than  the  exception. 


10  PART   I.     I'RIJJMI.XARV    I'RIXCII'LES  OF   PRACTICE 

Malocclusion. — The  terms  "dental  irregularity,"  and  "iiTegularity  of  the 
teeth,"  while  perfectly  proper  in  a  restricted  sense,  have  been  gradually  succeeded 
by  the  more  comprehensive  and  popular  term  "malocclusion,"  which  in  the  present 
wide  scope  of  its  meaning  refers  to  all  dental  and  dento-faeial  malpositions  which 
may  be  corrected  by  mechanical  forces  applied  to  the  teeth. 

Posed  and  Malposed. — Teeth  are  normally  posed  when  regular  or  in  normal 
positions.  The  terms  "malposed"  and  "malposition"  are  used  with  varying  shades 
of  distinction  as  synonymous  with  irregular  and  irregularity. 

Aligimient  and  Malalignment. — Teeth  are  in  alignment  when  they  are  in  proper 
relation  to  the  line  of  their  dental  arch.  A  tooth  or  teeth  in  malalignment  con- 
stitutes an  irregularity,  yet  all  the  teeth  of  the  dental  arch  may  be  in  perfect  align- 
ment with  the  dentures  in  malocclusion,  as  instanced  by  abnormal  protrusions  of 
the  upper  teeth  and  other  conditions. 

Interdigitate  and  Interdigitation  have  reference  to  any  closure  of  the  buccal 
teeth  in  which  the  cusps  of  one  denture  strike  fairly  into  the  occluding  sulci  of  the 
other.  When  the  teeth  are  in  normal  occlusion,  the  buccal  cusps  are  in  normal 
interdigitation.  When  the  buccal  cusps  interdigitate,  with  the  teeth  in  abnormal 
occlusion — as  in  upper  protrusions,  for  instance,  where  the  upper  buccal  cusps  are 
fully  the  width  of  a  premolar  in  front  of  a  normal  occlusion  with  the  lower — the 
cusps  are  in  abnormal  interdigitation  or  "malinterdigitation." 

Open-Bite  Malocclusion.' — When  the  labial,  or  "biting"  teeth  cannot  be 
brought  together,  through  an  occlusal  interference  of  the  back  teeth,  leaving  a 
space  of  more  or  less  width,  the  condition  may  be  properly  termed  an  "open-bite 
malocclusion."    See  Fig.  152,  Class  I,  Division  1. 

Close-Bite  Malocclusion. — The  opposite  condition  of  the  above  would  there- 
fore apply  to  those  cases  in  which  a  closure  of  the  back  teeth  causes  the  front  teeth  to 
pass  their  normal  occlusal  planes,  frequently  forcing  the  lower  incisors  deeply  into 
the  gum  back  of  the  upper  front  teeth.  See  Class  II,  Division  1.  This  may  be  an 
infra-occlusal  position  of  buccal  teeth,  or  a  supra-occlusal  position  of  the  labial  teeth. 

The  Occlusal  Plane. — When  the  lips  of  esthetic  facial  outlines  are  in  perfect 
repose,  the  standard  line  of  a  typical  occlusal  plane  should  be  even  with  or  but 
slightly  below  the  lower  edge  of  the  upper  lip,  which  should  indicate  the  normal 
line  of  the  occlusal  edges  of  the  upper  labial  teeth.  The  front  part  of  the  lower  plane 
curves  upward  to  a  point  slightly  above  this  to  allow  the  occlusal  ends  of  the  lower 
labial  teeth  to  pass  back  of  the  uppers.  From  this  point,  posteriorly,  the  plane 
curves  slightly  downward,  and  then  as  it  passes  the  first  molars,  it  again  curves 
slightly  upward. 

Infra  and  Supra-Occlusion  are  terms  which  refer  to  teeth  whose  occluding  surfaces 
are  below  or  above  the  normal  occlusal  plane.    See  "Intrusive"  and  "Extrusive." 

General  Bimaxillary  Supra  and  Infra-Occlusion. — We  frequently  meet  people 
whose  dentures  are  in  normal  occlusion,  and  not  protruded,  and  yet  they  cannot 
possibly  bring  their  lips  together  without  an  effort,  and  when  they  are  laughing  or 


CHAPTER   II.     NOMENCLATURE  11 

talking,  the  crowns  of  the  front  teeth,  and  often  the  gums  far  above,  are  in  unpleasant 
evidence.  This  is  because  the  teeth  are  too  long  in  relation  to  the  normal  occlusal 
plane,  and  the  condition  may  be  properly  termed  "General  Bimaxillary  Supra- 
Occlusion." 

Occasionally,  the  teeth  are  in  the  opposite,  or  infra-occlusal  malposition. 
This  does  not  refer  to  that  frecjuent  "close-bite  malocclusion"  found  in  Class  II  in 
which  the  lower  front  teeth  strike  into  the  gums  back  of  the  upper,  and  is  due  to  an 
infra-occlusal  position  of  the  back  teeth,  but  it  refers  to  cases  in  which  both  the 
front  and  the  back  teeth  are  too  short  in  relation  to  the  normal  occlusal  plane. 
Patients  with  this  character  of  malocclusion,  can  open  their  jaws  from  %  to  yi  oi 
an  inch  without  disturbing  a  reposeful  closure  of  the  lips,  and  when  the  jaws  are 
closed,  the  lips  in  contact  are  forced  forward  with  a  marked  and  unpleasant  redun- 
dancy of  lip  tissue.  This  condition  may  be  properly  termed  "General  Bimaxillary 
Infra-Occlusion."  See  description  and  illustration  of  this  character  which  is 
placed  in  this  work  in  Class  I,  Division  2. 

Mesial  and  Distal,  when  used  to  define  malpositions,  locations,  occlusion, 
movements,  etc.,  will  be  used  only  in  the  sense  in  which  these  terms  were  originally 
intended  to  be  used  in  dentistry,  i.  e.,  toward  or  from  the  median  line  in  a  direction 
along  the  curve  of  the  dental  arch.  Therefore,  they  should  not  be  used  as  they 
frequently  are  in  the  sense  of  anterior  and  posterior,  front  or  back,  or  protruded  and 
retruded,  except  in  referring  to  the  buccal  teeth.  Again,  if  the  lower  first  molars 
occlude  mesially  to  normal,  or  distally  to  normal  in  relation  to  the  upper  molars, 
this  malocclusion  should  not  be  defined  as  one  "in  mesial  malocclusion,"  or  one  in 
"distal  malocclusion,"  without  other  qualifications  as  it  frequently  is,  because  this 
term  has  reference  to  the  upper  teeth  as  well  as  to  the  lower  in  occlusal  contact. 
This  would  indicate  that  only  the  lower  denture  assumed  these  distal  and  mesial 
malpositions.  Moreover,  the  mesio-distal  relation  of  the  molar  occlusion  n\  no 
sense  defines  the  real  irregtilarity,  because  this  relation  does  not  necessarily  indicate 
that  the  lower  or  the  upper  teeth  are  protruded  or  retruded.  The  fault  may  be 
entirely  with  either  denture  alone,  or  it  may  be  partly  with  the  lower  and  partly 
with  the  upper  denture. 

Arch. — The  dental  arch  is  that  inscribed  by  the  teeth.  The  alveolar  arch, 
that  inscribed  by  the  alveolar  process  and  overlying  gum.  It  is  an  unfortunate 
confusing  misnomer  to  call  arch-bows,  "arches."  They  are  not  "arches"  in  any 
sense  of  the  word,  and  they  are  bows  for  correcting  dental  arches. 

Dome. — The  dome  of  the  oral  arch  refers  to  the  upper  curve  or  area  of  the 
roof  of  the  mouth. 

Zone  is  a  favorable  word  for  locating  sections  of  the  dental  and  alveolar  arches 
that  we  frequently  wish  to  refer  to  in  describing  different  characters  of  general 
malpositions  and  movements.  Dental  Zones  may  be  considered  as  narrow  band- 
like areas  extending  along  the  dental  arch  parallel  to  the  occlusal  plane,  as  "Occlu- 
sal, Gingival,  and  Apical  Zones."    (For  "Dento-Facial  Zones,"  see  Chapter  XXI.) 


12  PART   I.     PRELIMINARY   PRINCIPLES  OF   PRACTICE 

Malturned  is  used  in  reference  to  a  tooth  that  is  abnormally  turned  on  its 
central  axis.  The  term  "malturned,"  though  somewhat  of  a  mongrel,  is  much  pre- 
ferred to  "torsion"  and  "torso-occlusion,"  which  is  very  bad  and  improper.  The 
dictionary  states:  "Torsion  (torsio,  torquere),  the  act  of  twisting  a  body — 
such  as  a  thread,  wire,  rope,  etc.,  by  the  exertion  of  lateral  force  tending  to  turn 
one  end  or  part  of  it  about  a  longitudinal  axis,  while  the  other  is  held  fast  or  turned 
in  the  opposite  direction."  A  tooth  is  never  twisted  or  in  a  twisted  posture,  nor 
do  we  twist  teeth  as  we  do  a  string,  or  any  yielding  body.  We  rotate  them  bodily 
on  their  central  axes.  Moreover,  the  term  "torso  occlusion"  is  suggestive  of 
"torso,"  the  trunk  of  the  human  body. 

Rotate  is  used  in  reference  to  the  process  of  turning  a  tooth.  Many  authors 
have  heretofore  used  "rotate"  and  its  suffixes  to  define  both  position  and  action. 
The  same  is  true  of  "torsion."  The  author  finds  that  it  avoids  much  confusion  in 
teaching  and  writing — besides  being  more  proper — to  use  distinct  words  for  position 
and  action.     Thus  a  "malturned"  tooth  demands  "rotating"  force  for  its  correction. 

Compound  Terms. — The  adjectives  mesial,  distal,  labial,  buccal,  lingual,  and 
occlusal,  and  their  combinations  can  be  happily  used  to  exactly  define  certain 
malpositions,  movements,  points  of  attachment,  direction,  etc.  The  direction  in 
which  a  tooth  is  malturned  or  reciuires  rotating  on  its  central  axis  may  thus  be  fully 
defined  with  a  compound  word,  if  it  is  understood  as  in  other  departments  that  the 
first  niember  of  the  compound  word  indicates  the  location  upon  the  surface  of  the 
tooth,  and  the  last  member  the  direction  of  the  movement.  For  instance,  we  may 
say  that  a  central  incisor  is  malturned  labio-mesially,  or  that  it  requires  the  appli- 
cation of  labio-distal  rotating  force.  Again,  it  may  be  in  mesial,  distal,  labial, 
buccal,  or  lingual  inclination,  or  in  labial  or  lingual  malalignment,  etc. 

Anterior  and  Posterior  are  words  that  are  so  well  established  by  common  usage 
it  would  be  difticvilt  if  not  impossible  to  drop  them  from  our  nomenclature,  even  if 
we  wished.  When  used  to  define  relative  position  or  movement  in  a  direction  paral- 
lel to  the  median  line,  they  are  frequently  of  great  advantage. 

Trudo. — A  number  of  quite  commonly  employed  and  useful  English  terms  are 
derived  from  the  Latin  root  "trudo,"  "to  thrust."  The  syllable  "trude"  with  its 
prefixes  "pro"  (forward),  "re"  (backward),  "ex"  (out  from),  "in"  (into),  "con" 
(in  upon),  with  their  suf^xes,  "ed,"  "ing,"  "sion,"  and  "sive,"  gives  us  a  class  of 
words  of  distinct  and  scientific  applicability.  Moreover,  they  are  of  such  common 
usage  in  our  language,  and  especially  in  the  sciences  in  expressing  relative  posi- 
tions and  movements,  and  their  applicability  is  so  quickly  comprehended  by 
students,  it  seems  strange  that  so  many  orthodontic  teachers  and  authors  of  text- 
books in  their  nomenclatures  should  employ  in  their  place  terms  that  are  odd,  and 
of  very  uncommon  usage,  whatever  their  scientific  applicability. 

Protrude,  Retrude,  etc. — Teeth  are  in  a  protruded  or  retruded  position  only  in 
respect  to  the  esthetic  standard  of  dento-facial  relation,  and  in  no  instance  can  this 
be  determined  or  defined  by  the  occlusal  relation.    The  esthetic  facial  lines,  accord- 


CHAPTER  II.    NOMENCLATURE  13 

ing  to  the  type  of  the  physiognomy,  are  taken  as  a  standard  of  position,  and  there- 
fore should  not  be  confounded  with  the  relative  position  of  the  teeth  or  the  dentures 
in  relation  to  each  other.  If  the  teeth  are  in  front  of  a  line  which  forces  the  lip 
or  lips  forward  of  the  true  dento-facial  line,  they  arc  protruded  to  the  extent  of 
their  malposition,  and  are  denominated  Upper  Protrusion,  Lower  Protrusion,  or 
Bimaxillary  Protrusion.    The  same  is  true  in  regard  to  retruded  malpositions. 

The  front  teeth  alone  may  be  protruded  or  retruded,  or  these  adjectives  may 
lae  applied  to  the  entire  dentvires  or  even  the  jaws  in  these  characters  of  malre- 
lations  to  dento-facial  harmony. 

If  the  crowns  alone  are  protruded  with  labial  inclinations  forcing  the  orbicular 
portion  of  the  lip  or  lips  forward,  it  is  coronal  protrusion.  If  the  crowns  and  roots 
are  protruded  forcing  the  entire  labial  area  forward,  it  is  bodily  protrusion.  If  the 
jaws  arc  protruded,  it  is  maxillary,  or  mandibular  protrusion,  or  prognathism. 

Intrusive  and  Extrusive  are  relative  adjective  terms  which  refer  to  movement 
or  position  in  relation  to  the  socket  or  the  normal  occkisal  plane,  and  always  in  the 
line  of  the  central  axis.  For  instance,  a  tooth  in  a  supra-occlusal  malposition 
demands  an  intrusive  movement,  and  vice  vei'sa.  The  expression  "compressing 
teeth  into  their  sockets,"  is  quite  as  bad  form  as  "torso."  Nothing  is  "com- 
pressed," except  compressible  substances,  like  cotton,  wood,  etc.,  which  can  be 
forced  into  a  more  compact  form. 

Contrude  is  a  useful  word,  not  supplied  by  any  other,  to  indicate  an  abnormal 
inward  curve  of  any  portion  of  the  line  of  the  dental  arch.  Thus,  in  a  "club- 
shaped  arch,"  the  sides  are  contruded.  It  may  also  be  used  to  refer  to  a  single  tooth 
which  is  crowded  lingually  into  malalignment.  The  term  in  geology  refers  to  a 
downward  or  inward  curve  of  the  line  of  strata. 

Labial,  Lingual,  and  Buccal  are  terms  employed  to  define  position,  direction, 
or  movement.  For  instance,  the  front  teeth  are  moved  labially  when  they  are 
moved  forward  or  toward  the  lips,  etc. 

Gingival,  Occlusal,  Approximal,  etc.,  are  well  known. 

Rootwise  is  employed  to  dehne  position  or  direction  of  force.  Rootwise  attach- 
ments "are  those  which  extend  above  the  gingival  line  for  the  force  attachment." 
If  force  or  movement  is  in  a  rootwise  direction,  it  is  toward  the  ends  of  the  roots 
in  a  line  with  their  central  axes,  or  intrusively. 

Labial  Teeth  and  Buccal  Teeth. — It  is  frequently  desirable  to  speak  of  the 
six  front  upper  or  lower  teeth  as  having  moved  or  requiring  movement  in  phalanx. 
The  same  is  true  of  the  right  and  left  upper  and  lower  side  teeth.  Therefore,  the 
term  "Labial  Teeth"  will  be  used  to  refer  to  the  incisors  and  cuspids  in  single 
phalanx;  and  the  "Buccal  Teeth"  to  the  premolars  and  molars  in  single  phalanx. 

Front,  Back,  Upper,  and  Lower. — In  referring  to  the  general  location  of  the 
teeth,  the  terms  "Front"  and  "Back"  will  be  used  in  preference  to  the  terms 
"Anterior"  and  "Posterior,"  and  the  terms  "Upper"  and  "Lower"  instead  of 
"Superior"  and  "Inferior"  teeth. 


14  PART   I.     PRELIMINARY    I'RIXCiri.ES  OF   PRACTICE 

In  this  work,  the  terms  Cuspid  and  Canine  will  be  used  synonymously,  though 
preference  is  given  to  the  former.  Premolar  instead  of  Bicuspid;  Deciduous 
Molar  instead  of  "Premolar" ;  First  Permanent  Molar  instead  of  "Six  Year  Molar" ; 
Third  Molar  instead  of  "Wisdom  Tooth." 

In  the  present  unfixed  state  of  our  dental  nomenclature,  the  author  believes 
it  inadvisable  to  wholly  discard  the  use  of  any  term  which  by  long  usage  and  strict 
scientific  application  may  be  properly  applied,  and  especially  those  which  are  cor- 
rectly employed  by  our  best  writers. 

The  term  "Cuspid"  instead  of  "Canine"  is  the  choice  of  Dr.  G.  V.  Black  in 
our  leading  Dental  Anatomy.     In  a  letter  in  reference  to  these  terms  he  says: 

"I  wish  to  say  this:  that  Dental  Nomenclature  in  dentistry  is  not  necessarily 
dental  nomenclattire  in  comparative  dental  anatomy.  The  comparative  dental 
anatomist's  nomenclature  never  will  answer  the  ptirpose  of  the  dentist,  and  neither 
will  the  nomenclature  of  the  dentist  answer  the  purpose  of  the  comparative  dental 
anatomist,  and  the  ciuicker  this  is  recognized  the  better  it  will  be  for  all  parties. 
We  do  not  write  of  dog's  teeth  and  we  have  no  use  for  the  term  'canine  tooth'." 

The  author  does  not  object  or  refrain  from  using  any  advisedly  established 
term  which  is  applicable  and  calculated  to  convey  the  desired  meaning.  The 
term  "Canine"  has  come  into  quite  general  use  of  late,  and  the  fact  that  it  is 
wholly  adopted  by  the  "Cosmos,"  and  a  number  of  leading  journals  and  textbooks, 
are  good  reasons  for  adopting  it  in  this  work,  but  it  seemed  unreasonable  to  drop 
"Cuspid"  as  long  as  we  retained  "Bicuspid."  The  two  words  as  a  pair  were  plainly 
indicative:  the  one  referring  to  a  tooth  having  one  cvisp,  and  the  other  to  one  having 
two  cusps.    But  cuspid  is  so  fixed  by  usage  it  is  almost  impossible  to  drop  it. 

The  term  "Premolar"  when  referring  to  the  bicuspids  has  certain  objections, 
because  if  there  are  any  teeth  in  the  mouth  which  are  premolars  according  to  the 
strictest  meaning  of  the  term,  they  are  the  deciduous  molars,  as  these  are  the  only 
teeth  which,  in  form  and  function,  are  like  tlie  permanent  molars,  and  they  are 
also  "pre"  to  the  permanent  molars  both  as  to  position  and  time.  Dr.  Cryer 
rightfully  calls  them  premolars,  though  he  also  uses  this  term  in  referring  to  the 
bicuspids;  while  others  confine  the  term  to  the  bicuspids  alone.  The  fact,  however, 
that  "premolar"  instead  of  "bicuspid"  has  come  into  quite  general  use  by  ortho- 
dontists, and  also  because  it  has  been  adopted  by  many  of  the  latest  scientific 
works,  practically  necessitates  adopting  it  in  this  work. 

Unilateral,  indicating  location,  refers  to  one  side  of  the  mouth. 

Bilateral,  indicating  location,  refers  to  both  sides  of  the  mouth. 

Unimaxillary,  indicating  location,  refers  to  one  jaw. 

Bimaxillary,  indicating  location,  refers  to  both  jaws. 

The  term  Oro- Nasal  is  introduced  to  take  the  place  of  naso-pharyngeal,  when 
applied  to  the  passage  leading  from  the  mouth  to  the  nose. 

Oral  Element  is  an  indivisible  element  of  speech. 


CHAPTER   III 

DENTO-OCCLUSAL   CLASSIFICATION   OF   MALOCCLUSION 

Like  nomenclature,  it  is  important  that  the  student  should  acquire  a  perfect 
knowledge  of  the  accepted  classification  of  malocclusion  employed  in  the  textbook, 
at  the  very  beginning  of  his  study  of  orthodontia  in  order  that  he  may  be  able  to 
intelligently  locate  by  name  the  various  malocclusions  that  are  mentioned  in  the 
text,  as  he  progresses.  By  the  aid  of  the  "Table  of  Classes"  herewith,  to  which  the 
student  can  immediately  turn,  he  will  soon  familiarize  himself  with  the  special 
characters  of  the  Classes  and  their  Divisions. 

The  principal  object  of  a  classification  in  any  of  the  sciences  is  to  enable  one 
to  quickly  obtain  a  general  mental  grasp  of  the  thing  referred  to,  and  to  recognize 
it,  or  define  it  as  distingtiished  from  other  things  of  a  similar  nature,  thus  producing 
a  clear  mental  flash-light  word  picture  of  the  thing  itself.  This  is  accomplished 
through  a  systematic  arrangement  of  the  objects  or  material  into  distinct  groups, 
classes,  divisions,  types,  etc.,  each  one  of  which  is  characterized  by  some  stable 
peculiarity  in  form,  structure,  or  property  of  recurring  constancy,  not  found  else- 
where in  the  classification.  Therefore,  in  naming  a  class  in  any  classification  with 
the  division  of  that  class,  and  the  type  of  the  division  of  the  class,  we  have  presented 
a  mental  picture  of  the  thing  and  its  pectiliar  distinguishing  characteristics. 

In  an  attempt  to  follow  this  commonly  accepted  system  of  nomenclature  in 
classification  of  malocclusion  of  the  teeth,  we  are  confronted  with  somewhat  the 
same  difficulties  that  confront  the  science  of  medicine  in  classifying  diseases. 

In  orthodontia,  the  present  most  popularly  accepted  basis  for  the  classification 
of  malocclusion  is  the  disto-mesial  occlusal  relations  of  the  buccal  teeth.  This 
naturally  divides  malocclusions  into  three  classes  as  follows:  In  Class  I,  the  disto- 
mesial  occlusal  relations  of  the  buccal  teeth  are  normal  or  nearly  so.  In  Class  II, 
the  disto-mesial  occlusal  relations  of  the  lower  buccal  teeth  are  about  the  width  of 
a  cusp  distal  to  normal;  and  in  Class  III,  the  disto-mesial  occlusal  relations  of  the 
lower  buccal  teeth  are  about  the  width  of  a  cusp  mesial  to  normal. 

The  consistent  reason  for  this  natural  division  into  the  three  classes  is  as  fol- 
lows: In  a  normal  occlusion  of  the  teeth,  the  cusps  of  the  buccal  teeth  of  one  den- 
ture fit  evenly  and  anatomically  into  the  sulci  of  the  other.  During  the  eruptive 
stage,  if  from  some  cause  they  do  not  quite  take  this  exact  anatomic  relation,  the 
forces  of  mastication  soon  drive  them  fully  into  it  along  the  inclined  planes  of  the 
sliding  facets;  except  in  those  cases  where  certain  causes,  local  or  inherent,  have 
forced  the  teeth  to  erupt  so  that  the  crests  of  the  cusps  of  one  denture  are  more  or 
less  outside  the  grasp  of  the  normal  spheres  of  influence.    In  this  instance  they  at 

15 


16  PART   I.     PRELIMINARY   PRINCIPLES  OF   PRACTICE 

once  commence  to  drift  along  the  inclined  planes  toward  the  wrong,  or  abnormal 
sulci,  until  they  have  fitted  themselves  as  closely  as  possible  into  their  interlocking 
grasps,  with  the  result  that  the  bviccal  teeth  of  one  denture  in  relation  to  the  other, 
on  the  right  or  the  left,  or  both  sides,  are  commonly  found  to  occlude  in  normal,  or 
about  the  width  of  a  ctisp  mesial  or  distal  to  normal  occlusion. 

As  the  teeth  erupt  and  come  into  contact  with  their  masticating  fellows, 
they  are  often  forced  to  move  disto-mesially  and  bucco-lingually,  from  their 
erupted  positions  through  the  fitting  processes  of  their  cusps,  in  exactly  the  same 
way  that  they  are  moved  by  orthodontic  forces.  There  is  no  doubt  that  whole 
dentures  are  frequently  caused  to  move  antero-posteriorly  to  a  considerable  extent 
by  the  mesial  or  distal  movement  of  their  masticating  teeth  in  nature's  process 
of  fitting  the  cusps  into  their  normal  or  abnormal  interdigitating  sulci,  which  con- 
stitutes the  basis  of  our  present  three  classes  of  malocclusion. 

While  this  dento-occlusal  classification  here  presented  is  qviite  different  from 
the  Angle  classification,  it  will  be  found,  by  teachers  and  students,  of  the  greatest 
practical  value,  enabling  a  systematic  presentation  of  the  most  advanced  prin- 
ciples of  dento-faeial  orthopedia,  at  present  unequaled  by  any  other  classification. 
For  the  very  great  advantage  of  perfect  harmony  and  unanimity  in  our  literature 
and  teaching,  the  author  would  have  gladly  adopted  the  Angle  classification  were 
it  not  for  the  fact  that  as  it  now  stands  it  cannot  be  made  to  express  a  large  number 
of  very  important  characters  of  malocclusion  which  should  be  fully  recognized 
and  systematically  scheduled  as  independent  Divisions  or  Types  of  Divisions  of 
one  or  the  other  of  the  three  Classes.  Furthermore,  the  Angle  classification  does 
not  recognize  those  ivide  differences  in  the  character  of  certain  malocclusions  which 
have  the  same  disto-mesial  occlusion  of  the  buccal  teeth.  It  will  be  found  by  a 
careful  study  of  malocclusions  that  these  dift'erences  in  dento-facial  characters  and 
demands  of  treatment  ivithin  each  class  are  fully  as  great  and  quite  as  important  in 
orthodontia  as  the  dift'erences  which  arise  between  one  class  and  another.  Note  the 
distinctively  different  characters  within  each  one  of  the  three  classes  shown  by 
the  chart.  When  we  take  the  disto-mesial  occlusal  relations  of  the  buccal  teeth 
as  the  distinguishing  bases  of  the  three  classes,  we  should  necessarily  place  in  each 
one  of  the  classes — either  in  divisions  or  types — all  the  distinctive  recurring  charac- 
ters which  correspond  to  the  chosen  basis  of  the  class. 

When  we  name  a  class  to  which  a  certain  malocclusion  belongs,  we  convey  a 
mental  picture  of  only  the  disto-mesial  occlusal  relations  of  its  buccal  teeth,  and 
nothing  more,  except  the  fancied  conception  of  its  real  character  and  dento-facial 
relations.  And  when  we  go  further  and  name  the  Division  of  its  class,  we  still 
have  placed  it  only  as  one  of  a  family  of  malocclusions  whose  individual  members 
may  differ  quite  decidedly  from  each  other  when  dento-facially  considered,  though 
all  are  alike  in  one  distinguishing  characteristic  of  buccal  occlusion.  Neither  can 
we  place  in  the  mind's  eye  the  individually  completed  characters  of  the  case  in  hand 
until  we  have  named  its  Type,  its  Division,  and  its  Class.    There  are,   however, 


CHAPTER   III.     DEXTO-OCCLUSAL  CLASSIFICATION  17 

certain  divisions  whose  different  types  are  so  similar  they  require  no  mention  in  a 
classified  chart,  though  in  practical  treatment  they  may  differ  considerably;  all 
of  which  with  a  variety  of  variations  should  be  fully  outlined  in  the  textbook 
teaching. 

In  this  classification,  while  the  class  to  which  a  malocclusion  belongs  is  deter- 
mined solely  by  its  occlusal  disto-mesial  relations,  its  family  or  Divisional  charac- 
teristic is  based  upon  its  general  dento-facial  relations,  and  when  there  are  found  to 
be  distinctive  variations  within  the  Division,  they  constitute  its  Types.  But 
when  these  distinctive  type  variations  are  common  to  all  the  Divisions  of  the 
Class,  they  are  placed  under  "Concomitant  Types"  as  in  Class  II. 

As  a  large  majority  of  orthodontists  have  already  become  accustomed  to 
divide  malocclusions  according  to  the  three  distinct  occlusions  of  the  buccal  teeth 
— normal,  mesial,  and  distal — the  placing  of  all  the  commonly  recurring  dento- 
facial  types  which  have  a  similar  occlusion,  in  one  class,  will  doubtless  give  a  greater 
opportunity  to  define  their  wide  differences  in  character  and  demands  of  treatment, 
and  thus  prevent  as  far  as  possible  the  too  common  error  of  treating  cases  alike  on 
the  basis  of  their  occlusal  similarity.  It  is  hoped  also  that  it  will  tend  toward 
preventing  the  insistence  of  placing  certain  dentures  in  a  normal  occlusion  whose 
deforming  facial  protrusions  demand  extraction.  And  on  the  other  hand,  it  is  most 
earnestly  hoped  that  it  will  prevent  the  extraction  of  teeth  by  those  who  unfor- 
tunately have  made  a  wrong  interpretation  of  the  author's  teaching.  It  certainly 
should  appeal  to  those  orthodontists  who  favor  the  occlusal  classification,  and  whose 
highest  aim  in  practice  is  a  truthful  and  scientific  diagnosis  of  their  cases. 

To  those  who  beHeve  that  teeth  should  never  be  extracted  for  the  dento- 
facial  correction  of  the  decided  unimaxillary  and  bimaxillary  protrusions.    Dr.  i 
Angle's  classification  will  be  found  quite  consistent  with  that  system  of  practice. 

It  was  because  of  the  marked  differences  in  the  character,  facial  outlines, 
and  required  treatment  of  malocclusion  in  Class  II — in  which  the  upper  denture  is 
about  the  width  of  a  cusp  in  front  of  a  normal  occlusion — that  led  the  author  to 
divide  this  class  in  a  former  classification,  into  Classes  II  and  III,  as  he  beUeved 
this  would  more  strongly  emphasize  the  importance  of  a  dift'erential  diagnosis  of 
dento-facial  characters  having  the  same  occlusion  of  the  teeth,  certain  types  of 
which  demand  the  extraction  of  teeth  in  their  proper  correction,  while  with  others, 
such  a  procedure  would  be  decided  malpractice.  In  other  words,  it  was  his  desire 
to  free  it  from  the  mechanical  and  mathematical  trend  toward  which  the  science 
seemed  to  be  drifting,  and  to  induce  a  deeper  consideration  and  study  of  facial  art 
and  beauty  as  important  factors  of  diagnosis  and  treatment.  "With  the  present 
advancement  in  the  practical  principles  of  orthodontia,  it  is  hoped  that  a  systema- 
tized arrangement  of  all  the  distinctive  types  of  malocclusion  under  three  heads, 
upon  the  basis  of  their  occlusal  peculiarity,  will  enable  a  full  appreciation  of  the 
wide  differences  in  dento-facial  outlines  with  patients  having,  practically,  the  same 
occlusal  relations  of  the  teeth. 


18  PART   I.     PREUMIXARV   PRIXCIPLES  OF  PRACTICE 

By  carefvilly  scanning  the  author's  present  classification,  it  will  be  seen  that 
while  the  distinct  characters  of  malocckision  are  now  divided  among  the  three 
classes  upon  the  basis  of  their  disto-mesial  occlusion,  their  true  basis  of  diagnosis 
and  treatment  is  dependent  very  largely  upon  the  facial  outlines  in  relation  to  the 
standard  of  esthetic  perfection  for  the  individual,  because  it  is  not  otherwise  pos- 
sible as  a  gtiide  to  treatment  to  determine  whether  the  dentures — one  or  both — are 
really  protruded  or  retruded. 

While  the  dento-occlusal  classification  possesses  the  advantage  of  enabling 
us  to  divide  and  segregate  a  great  variety  of  malocclusions  into  a  small  number  of 
classes,  it  will  be  found  as  one  becomes  more  and  more  advanced  in  the  science  of 
orthodontia,  that  there  will  arise  a  fuller  appreciation  of  the  fact  that  the  disto- 
mesial  occlusion  of  the  buccal  teeth  is  a  very  uncertain  and  often  misleading  guide 
as  a  basis  of  diagnosis  in  determining  real  conditions,  and  the  kind  of  treatment 
demanded,  because  in  every  one  of  the  three  classes,  if  all  the  distinct  characters 
inside  of  each  class  are  tabulated,  there  will  be  found  a  remarkably  diverse  variety 
of  dento-facial  deformities. 

One  of  the  most  dangerous  features  of  the  Angle  classification,  as  formerly 
set  forth,  and  one  which,  strange  to  say,  has  tended  to  popularize  it  in  the  minds  of 
orthodontists,  is  the  universally  applied  teaching  that  when  dentures  are  placed  in 
normal  occlusion,  the  facial  outlines  will  take  care  of  themselves;  and,  therefore, 
the  highest  possible  orthodontic  attainment  for  that  individual  is  accomplished. 
If  this  were  as  true  as  it  is  believed  by  many,  it  would  simplify  the  whole  practice 
of  orthodontia,  because  in  theory  it  eradicates  the  necessity  of  a  deep  comprehen- 
sion of  dento-facial  art,  and  many  other  important  principles  which  are  so  difficult 
for  orthodontists  to  understand. 

A  careful  study  of  the  great  question  of  extraction  which  is  so  largely  dependent 
upon  Causes,  and  which  lies  at  the  very  foundation  of  advanced  dento-facial 
orthopedia,  must  convince  every  receptive  truth-seeking  mind  of  the  delusiveness 
of  a  teaching  which  asserts  the  universal  applicability  of  the  "normal  occlusion 
theory," — which  is:  that  "every  tooth  or  its  artificial  substitute  is  necessary  for 
the  perfect  correction  of  dental  or  dento-facial  malocclusions." 

In  adopting  the  occlusal  classification,  therefore,  it  should  be  remembered 
that  the  disto-mesial  character  of  a  buccal  malocclusion  is  no  more  or  less  than  one 
of  the  incidents  of  the  case  in  hand,  requiring  correction  if  demanded  along  with 
other  malpositions  which  may  be  present,  and  which  are  equally  important  to 
correct.  It  is  one  moreover  that  demands  to  the  fullest  extent  that  the  masticating 
cusps  shall  be  in  perfect  interdigitating  occlusion ;  and  furthermore — it  goes  without 
saying — they  should  always  be  placed  in  normal  occlusion,  except  in  those  com- 
paratively few  instances  where  this  rule  is  inconsistent  with  imperative  facial 
demands. 

There  are,  however,  certain  special  and  quite  common  malpositions  which  are 
fovmd  in  every  one  of  the  three  classes,  because  they  arise  from  local  causes  which 


CHAPTER   HI.    DENTO-OCCLUSAL  CLASSIFICATION 


19 


Classified  Table  of  Dento-Facial  Malocclusions 


CLASS  I.     NORMAL  DISTO-MESIAL  OCCLUSION  OF  THE  BUCCAL  TEETH. 
DIVISION  1:     LOCALLY  CAUSED  DEXTO- FACIAL  MALOCCLUSIONS. 

Type  A:     unilateral  maleruption  of  cuspids. 
Type  B:     bilateral  maleruption  of  cuspids. 

Type  C:       bilateral   maleruption  of  cuspids  requiring  extraction.     (From  Class  II) 
Type  D  :      protrusion  of  upper  front  teeth.      (From  Thumb  Sucking) 
Type  E:       RETRUSION  of  upper  front  teeth.       (Treated  in  Division  2.  Class  III) 

Type  F:     lateral  malocclusion. 
Type  G:    open-bite  malocclusion. 

DIMSION  2:     BIMAXILLARY  PROTRUSION  AND  RETRUSION. 


CLASS  II.     DISTAL  MALOCCLUSION  OF  LOWER  BUCCAL  TEETH. 
DIMSION  1:     RETRUSION  OF  LOWER  DENTURE. 

Type  A:    pronounced  retrusion  of  lower  denture,  with  upper  normal. 
TypeB:     moderate  retrusion  of  the   lower  denture,  with  protrusion  of 
the  upper  denture. 

DIMSION  2:     PROTRUSION  OF  THE  UPPER,  WITH  LOWER  NORMAL. 

Type  A: 
Type  B: 
Type  C  : 
Type  D: 


UPPER  CORONAL  PROTRUSION. 

UPPER  BODILY  PROTRUSION. 

UPPER  CORONAL  PROTRUSION  WITH  APICAL  RETRUSION. 

UPPER  APICAL  PROTRUSION. 


CONCOMITANT  CHARACTERS  OF  CLASS  II." 

RETRUSION  OF  THE  MANDIBLE  AND  LOWER  DENTURE. 
CLOSE-BITE  MALOCCLUSION. 
MALERUPTION  OF  CUSPIDS.      (Treated  in  Class  I) 


CLASS  III.     MESIAL  MALOCCLUSION  OF  LOWER  BUCCAL  TEETH. 

DIVISION  1:     BODILY  RETRUSION  OF  THE  UPPER  DENTURE  AND  MAXILLA. 

(With  lower  normal  though  apparently  protruded) 

DIVISION  2:     CONTRACTED  RETRUSION  OF  THE  UPPER  DENTURE. 

(Due  to  inhibited  development  of  Maxilla) 

DIVISION  3:     RETRUSION  OF  THE  UPPER  WITH  PROTRUSION  OF  LOWER 
DENTURE. 

(With  no  protrusive  position  of  the  Mandible) 

DIMSION  4:     RETRUSION  OF  THE  UPPER  WITH  PROGNATHIC  MANDIBLE. 

(Commonly  accompanied  with  Open-Bite  Malocclusion) 


20  PART   I.     PRELIMINARY  PRINCIPLES  OF  PRACTICE 

may  attack  any  inherited  disto-mesial  occlusion  of  the  teeth,  and  therefore  they 
cannot  be  classified  as  special  divisions  or  types  of  any  one  particular  class,  not- 
withstanding the  fact  that  they  frequently  dominate  and  characterize  the  whole 
malocclusion  of  the  case  in  hand.  This  refers  to  Maleruption  of  Cuspids,  Thumb- 
sucking  Protrusions,  Lateral  Malocclusion,  Open-Bite  Malocclusion,  Infra  and 
Supra-Occlusions,  Malalignments,  Malturned  Teeth,  Contracted  and  Expanded 
Arches,  Abnormal  Interproximate  Spaces,  and  Impacted  Teeth.  It  is  quite  as 
important  that  the  principles  and  treatment  of  these  malocclusions  be  taught,  as 
those  of  the  distinctly  classifiable  characters. 

Inasmuch  as  the  first  four  of  this  group  produce  at  times  quite  marked  facial 
imperfections,  and  as  all  locally  caused  malocclusions  arise  most  frequently  in 
connection  with  normal  occlusions,  these  special  characters  of  malocclusion  are 
placed  in  the  Practical  Treatment  of  Class  I,  Division  1.  The  Practical  Treat- 
ment of  the  rest  of  this  sj;n)up  is  fully  described  in  Part  VII. 

In  regard  to  the  Classified  Table  of  Dento-Facial  Malocclusions  here  presented, 
it  should  be  understood  that  only  the  distinguishing  types  of  the  different  Divisions 
of  the  Classes  are  stated  in  the  Table.  Many  of  these  Divisions  possess  a  variety 
of  Types  which  demand  variations  in  treatment.  These  will  be  found  fully  de- 
scribed and  illustrated  from  cases  in  practice,  with  their  diagnosis  and  treatment 
in  the  "Practical  Treatment  of  Dento-Facial  Malocclusion,"  in  Part  VI  of  this  work. 


PART   II 


The  Etiology  of  Malocclusion 

with  Reference  to 

Principles  of  Diagnosis  and  Treatment 


ETIOLOGY  OF  MALOCCLUSION 


CHAPTER   \y 

ETIOLOGIC   PRINCIPLES   OF   MALOCCLUSION   WITH   REFERENCE  TO 

TREATMENT 

The  common  causes  of  the  different  types  of  malocclusion  will  usually  be 
found  in  this  work  in  connection  with  their  practical  treatment.  There  are,  how- 
ever, certain  underlying  principles  which  must  govern  an  intelligent  determination 
of  so  many  of  the  most  prolific  causes  of  dental  and  dento-facial  malpositions,  it 
seems  important  to  consider  this  subject  extensively  in  its  general  relations  to  the 
science  of  orthodontia.  While  there  are  certain  conditions  of  which  it  is  impossible 
to  determine  definitely  the  cause,  though  it  may  lie  within  the  field  of  conjectural 
possibility,  there  are  other  conditions  which  when  examined  in  the  light  of  intelli- 
gent investigation  can  be  seen  to  have  arisen  undoubtedly  from  heredity  or 
certain  well  known  postnatal  causes.  There  are  also  a  number  of  malocclusions 
which  are  the  final  result  of  a  series  of  causes,  one  following  as  a  scciuence  of  the 
other. 

So  many  of  the  more  pronounced  dento-facial  malocclusions  arise  through  one 

or  more  of  the  many  channels  of  heredity,  or  from  the  law  of  natural  variation,  a 

brief  review  of  some  of  the  well  established  principles  of  biology  which  relate  to  this 

subject,  seems  indispensable  to  an  intelligent  understanding  of  all  the  etiologic  factors 

under  consideration. 

Unknowable  Causes 

In  orthodontia,  we  are  mainly  engaged  with  treating  results  from  causes  that 
are  inactive  at  the  time;  and  this  is  true  of  all  cases,  except  the  malocclusions  or 
threatened  malocclusions  of  childhood  in  which  the  cause  is  active.  Therefore, 
in  many  cases,  to  know  the  cause  which  may  be  far  in  the  past,  has  been  considered 
heretofore  of  no  practical  advantage  so  far  as  the  treatment  of  the  particular  case 
in  hand  is  concerned.  But  this  does  not  lessen  the  importance  of  a  knowledge  of  all 
causes  from  an  educational  orthodontic  standpoint,  or  the  necessity  at  times  of 
positively  determining  whether  a  certain  condition  has  arisen  from  heredity  or 
from  some  local  cause.  Moreover,  it  is  especially  important  to  fully  understand 
the  causes  which  arise  from  improper  or  inadequate  care  and  treatment  of  children's 
teeth,  and  to  be  able  to  recognize  all  conditions  prevalent  with  children,  which  tend 
to  produce  malocclusions.  A  special  chapter  is  devoted  to  this  branch  of  the 
subject. 

23 


24  PART   II.     ETIOWCY   OF   MALOCCLUSION 

Throuj^h  advanced  training  and  modern  equipment,  the  unknown  causes  of 
malocclusion  are  gradually  being  reduced  to  a  minimum.  Formerly,  it  was  im- 
possible to  determine  why  certain  teeth  did  not  erupt.  Now,  the  radiograph  tells 
us  why  and  much  more  that  is  of  the  greatest  advantage  in  dentistry.  (See  Chap- 
ter LI.)  It  may  show  that  the  germs  of  the  said  tooth  or  teeth  are  extinct,  and  we 
may  find  upon  investigation  that  this  is  a  family  peculiarity  found  in  one  parent 
or  the  other,  and  perhaps  known  to  have  come  down  through  several  generations, 
proving  atavism.  Or  the  radiograph  may  show  that  the  failure  of  the  teeth  to  erupt 
is  due  to  one  or  more  supermmierary  teeth  or  odontomata  buried  in  the  alveolar 
process  in  such  a  position  as  to  prevent  the  desired  eruption;  and  if  it  is  a  cuspid, 
we  may  find  it  lying  at  a  decided  abnormal  angle  with  its  occlusal  end  near  the  cen- 
tral incisor,  deeply  imbedded  under  the  process.  Though  we  may  never  know  the 
prime  causes  of  these  conditions,  we  can  now  more  intelligently  proceed  to  the 
correction  of  their  results.  This  is  but  one  of  the  many  examples  illustrative  of  the 
progress  and  evolution  of  ideas  relative  to  causes  and  many  other  things  pertaining 

to  orthodontia. 

Compound  Causes 

There  are  many  malocclusions  which  arise  from  certain  evident  local  causes, 
of  which  the  primary  cause,  or  the  cause  of  the  cause,  is  quite  obscure.  With 
other  cases,  the  primary  cause  of  the  local  or  immediate  cause  is  plainly  heredity, 
or  some  other  local  cause.  One  of  the  simple  instances  of  this  is  the  low  attachment 
of  the  frenum  of  the  upper  lip,  whose  muscular  fibers  extend  through  the  proximal 
space  between  the  central  incisors  with  attachments  to  the  lingual  aspects  of  the 
ridge,  and  whose  local  action  tends  to  separate  the  centrals  with  every  movement 
of  the  lip.  No  intelligent  person  can  claim  that  this  character  of  frenum  could 
possibly  arise  from  a  local  cause ;  besides  it  has  been  frecjuently  found  following  the 
same  condition  in  one  of  the  parents,  proving  direct  heredity ;  though  one  can  under- 
stand how  this  abnormality  of  the  frenum,  and  many  other  anatomic  anomalies 
might  arise  originally  in  a  moderate  degree  from  the  law  of  natural  variation,  which 
is  neither  heredity  nor  local  causes,  as  will  be  explained  in  Chapter  VI. 

Crowded  malalignments  of  the  upper  teeth  amounting  to  many  of  the  most 
decided  malocclusions,  are  often  caused  by  a  lack  of  growth  development  of  the 
superior  maxilla  during  the  early  years  of  childhood.  This,  in  turn,  is  mainly  due 
to  continued  early  mouth-breathing,  thus  depriving  the  nasal  passages  and  sinuses 
of  the  natural  nutrient  forces  of  air  upon  which  the  lining  membranes  are  de- 
pendent for  their  health  and  functional  activities,  and  in  turn  all  the  connecting 
bones  dependent  vipon  the  health  of  these  tissues  for  their  normal  growth  develop- 
ment. This  deprivation  when  long  continued  will  at  tinies  force  the  sensitive  mu- 
cous membranes  into  a  chronic  inflammatory  state,  resulting  at  times  in  hyper- 
trophied  walls  dripping  with  diseased  exudations  which  the  stagnated  action  of 
its  cilia  are  unable  to  eliminate  as  they  would  in  health,  resulting  finally  in  a  partial 
or  complete  inhibition  of  the  normal  growth  development  of  the  maxilla,  and  a 


CHAPTER   IV.     ETIOLOGIC  PRIXCIPLES  25 

variety  of  dental  and  dento-facial  malocclusions,  and  even  general  physical  and 
mental  inhibitions,  through  some  mysterious  disturbances  of  those  glands  or 
ganglia  which  preside  over  normal  developing  activities. 

The  early  mouth-breathing  habit  may,  in  turn,  be  due  to  any  one  or  more  of 
three  local  causes,  i.  c,  chronic  rhinitis,  adenoid  vegetations,  and  enlarged  tonsils, 
which  result  in  a  partial  or  complete  stenosis  of  one  or  both  nasal  fossae;  and  while 
it  is  conceded  that  the  abnormal  activities  of  these  diseases  are  mainly  diie  to  some 
local  infection,  no  one  can  assert  that  the  peculiar  glandular  structures  in  the  nose 
and  naso-pharynx  were  not  constitutionally  the  predisposing  cause,  while  other 
children  with  more  normally  inherited  structures  would  be  immune  to  the  same 
infection.  [Moreover,  it  is  a  well  known  fact  that  abnormally  enlarged  tonsils  are 
due  to  heredity.  Jackson  says:  "Chronic  enlargement  of  tonsillar  tissue  is  one  of 
the  causes  of  mouth-breathing.  It  is  a  disease  of  child  life.  Some  authors  claim 
that  enlargement  of  these  glands  has  been  observed  in  children  born  prematurely, 
indicating  direct  heredity." 

While  the  evidence  instanced  does  not  necessarily  prove  that  the  condition 
did  not  arise  from  intra -uterine  infection,  there  are  any  number  of  instances 
which  do  prove  that  enlarged  tonsils  frequently  arise  from  heredity.  Moreover, 
there  is  such  an  intimate  relation  between  the  tonsillar  glands  and  those  from 
which  adenoids  develop,  they  may  reasonably  be  inchided.  In  one  family  of  three 
boys  who  came  under  the  intimate  observation  of  the  atithor,  the  tonsils  were  all 
abnormally  large  in  their  most  quiescent  state,  but  from  the  slightest  exposure  and 
even  from  unknown  causes  they  would  pass  quickly  into  active  inflammatory 
conditions  of  the  most  painful  and  obstructive  character.  The  mother  and  grand- 
mother of  these  boys  had  both  been  afflicted  with  these  same  conditions,  during 
childhood,  and  the  mother  still  retained,  in  a  lessened  degree,  the  same  predisposing 
tendency. 

It  will  be  seen  by  this  that  there  may  be  at  times  four  definite  stages  of  causes — 
one  dependent  upon  and  following  the  other — before  the  final  result  of  maloc- 
clusion: First,  heredity;  second,  enlarged  tonsils  or  adenoids;  third,  mouth- 
breathing;  fourth,  inhibited  growth  of  maxilla  with  its  concomitant  contraction, 
followed  by  crowded  malalignments;  open-bite  malocclusions;  upper  retrusions, 
etc.  During  the  sleeping  hours,  these  causes  are  most  active  when  the  mouth  is 
commonly  stretched  widely  open  with  the  masseter  and  buccinator  muscles  pressing 
in  on  immature  arches  narrowing  them  and  raising  the  domes,  and  aided  by  the 
strong  pressure  of  air  striking  the  vaults.  Again,  the  mechanical  action  of  the 
various  forces  of  the  muscles  upon  immature  mandibles  held  long  in  that  position 
is  the  main  cause  of  open-bite  malocclusions,  as  is  fully  explained  in  Class  I, 
"Open-Bite  Malocclusion." 

While  it  is  true  that  a  very  large  proportion  of  pronounced  malocclusions  of 
Classes  II  and  III  arise  in  the  main  from  some  form  of  heredity,  it  is  nevertheless 
true  that  certain  dominating  local  causes  arising  in  connection  with  these  cases,  will 


26  PART   II.     ETIOLOGY   OF   MALOCCLUSION 

impress  themselves  upon  them  in  such  a  manner  as  to  quite  decidedly  change  the 
main  inherited  type,  and  give  the  impression  that  the  malocclusion  is  due  wholly 
to  local  causes. 

It  is  true  also,  that  many  pronounced  malocclusions  of  these  two  Classes  are 
caused  wholly  by  local  causes,  even  to  the  full  disto-mesial  malrelations  of  the  buccal 
occlusion. 

One  of  the  most  pronounced  and  interesting  incidents  which  arises  wholly 
from  a  combination  of  local  causes,  is  the  mesio-distal  malocclusion  of  Class  II 
with  its  resultant  dento-facial  disharmonies.  Again,  instances  arise  in  children  of 
inherited  normal  occlusions  in  which  the  early  habit  of  thumb-sucking  produces 
all  the  characteristic  malrelations  of  the  labial  teeth  and  deforming  facial  outlines 
of  pronounced  upper  protrusions.  In  other  cases  of  inherited  normal  occlusions, 
the  early  loss  of  the  deciduous  upper  molars  is  frequently  followed  with  a  mesial 
malocclusion  of  the  upper  buccal  teeth,  and  this  in  many  instances  results  in  a  full 
malinterdigitation  of  buccal  cusps.  This  is  one  of  the  frequent  causes  of  malerup- 
tion  of  vipper  cuspids.  When  these  two  causes  arise  in  the  same  case,  as  they  un- 
doubtedly do  at  times,  the  resultant  malocclusion  may  have  all  the  dental  and 
dento-facial  characteristics  of  a  pronounced  upper  protrusion,  and  wholly  from 
a  combination  of  local  causes. 

Relation  of  Causes  to  Treatment 

While  the  practice  of  orthodontia  is  ciuite  different  from  the  practice  of  medicine 
in  which  the  removal  of  the  cause  is  the  prime  factor  of  treatment,  and  while 
it  is  true  that  we  mainly  correct  conditions  by  mechanical  procedures  from  the 
standpoint  of  their  existent  malpositions,  it  is  nevertheless  frequently  of  the  greatest 
importance  to  know  whether  the  malocclusion  arises  from  heredity,  or  from  causes 
operative  after  birth,  because  this  may  be  the  only  guide  to  correct  treatment. 

For  example,  one  of  the  most  common  forms  of  malocclusion  is  that  which  is 
characterized  by  a  maleruption  of  the  upper  cuspids,  which  is  immediately  due  to  a 
partial  or  complete  closure  of  the  spaces  between  the  lateral  incisors  and  first 
premolars.  Let  us  suppose  that  a  case  of  this  character  at  the  age  of  ten  or  twelve 
presents  for  treatment,  and  we  find  upon  an  examination  that  the  upper  buccal 
teeth  are  in  mesial  malocclusion  with  the  lowers  to  the  extent  that  the  crests  of  the 
mesio-buccal  cusps  of  the  upper  first  molars  are  slightly  in  front  of  the  mesio-buccal 
cusps  of  the  lowers,  instead  of  closing  into  the  sulci  between  the  mesial  and  distal 
buccal  cusps  of  the  lowers  as  they  should.  And  when  we  compare  the  relations  of 
the  lower  denture  to  the  mandible — the  lower  lip  with  the  chin — and  the  chin  to 
the  general  facial  outlines,  we  find  that  the  malocclusion  is  not  due  in  the  slightest 
degree  to  a  retrusion  of  the  lower  denture,  it  being  in  perfect  dento-facial  relation; 
consequently  the  upper  buccal  teeth  being  in  mesial  malposition  more  than  one- 
half  the  width  of  a  cusp,  they  are  protruded  to  that  extent  in  relation  to  dento- 
facial  harmony. 


CHAPTER   IV.    ETIOLOGIC  PRINCIPLES  27 

If  it  is  true  that  this  is  caused  by  a  premature  loss  of  upper  deciduous  teeth 
permitting  the  buccal  teeth  to  drift  forward  of  their  normal  positions,  or  if  it  has 
arisen  from  any  of  the  local  cavises,  fully  explained  in  other  chapters,  it  should  be 
our  greatest  endeavor  to  force  the  buccal  teeth  back  to  the  normal  relations  and 
occlusion  which  nature  intended  they  should  occupy.  But  if,  on  the  other  hand,  we 
find  that  the  mesial  malrelations  of  the  upper  buccal  teeth  have  arisen  from  hered- 
ity— this  diagnosis  being  frequently  confirmed  by  protruding  types  of  upper 
teeth  in  the  same  family,  or  relatives,  and  the  absence  of  any  indication  of  a  local 
cause — it  would  show  that  the  front  teeth  of  our  patient  would  also  have  been  pro- 
truded had  not  the  cuspids  been  forced  out  of  alignment — not  by  a  mesial  movement 
of  the  buccal  teeth,  as  in  the  other  instance — but  by  the  incisors  which  were  held 
back,  or  forced  back,  by  pressure  of  the  lips.  We  would  vmder  these  conditions 
hesitate  before  attempting  to  move  the  upper  buccal  teeth  distally  to  the  extent 
that  would  be  necessary  to  place  them  in  normal  occlusion  with  the  esthetically 
posed  lower  denture,  for  many  reasons,  all  of  which  are  fully  outlined  in  the  prac- 
tical consideration  and  treatment  of  this  malocclusion. 

The  older  members  of  the  dental  profession  will  remember  many  cases  like  the 
above  which  have  been  very  satisfactorily  corrected — occlusally  and  dento- 
facially — by  no  other  treatment  than  the  simple  extraction  of  the  first  upper  pre- 
molars. This  allowed  the  cuspids  to  take  their  proper  places  in  relation  to  the  un- 
protruded  lower  teeth,  and  the  cusps  of  the  upper  buccal  teeth  to  become  adjusted 
to  a  mesial  interdigitation  through  use,  with  quite  an  adequate  masticating  occlu- 
sion. It  was  through  successes  of  this  kind  by  dentists  in  the  early  years  of  ortho- 
dontia, as  stated  elsewhere,  that  led  to  the  criminal  extraction  of  thousands  of 
teeth  in  cases  of  crowded  malalignments;  and  especially  where  the  cuspids  were 
forced  to  erupt  through  the  gums  above  their  proper  positions.  Whereas,  we  now 
know  that  among  the  frequent  malocclusions  of  this  character  there  is  probably 
not  more  than  one  case  in  ten  for  which  extraction  is  indicated.  This  is  only  one 
of  the  many  examples  which  may  be  cited  showing  the  importance  of  correct  dif- 
ferentiation in  diagnosis  between  conditions  which  arise  through  the  channels  of 
heredity  and  those  from  local  causes. 

Until  the  acceptance  of  modern  principles  of  biology,  the  theory  of  special 
creations  led  to  the  gravest  errors  relative  to  causes.  It  is  unfortunate  in  this  day 
of  advancement  that  prominent  teachers  so  frequently  interlard  their  teachings 
with  statements  which  are  wholly  dependent  upon  the  unscientific  phases  of  belief 
that  have  been  long  discarded  by  all  well  informed  minds. 

If  it  were  true  that  "all  malocclusions  arise  from  local  causes,"  as  has  been 
repeatedly  claimed,  and  that  the  "placing  of  dentures  in  normal  occlusion  will 
invariably  be  followed  by  harmony  and  perfection  of  facial  outlines  according  to 
the  type  of  the  individual,"  many  of  the  difficult  problems  of  orthodontia  would 
not  arise.  It  would  completely  exclude  the  difficult  question  of  extraction  which 
has  led  so  many  into  quagmires  of  malpractice;  and,  furthermore,  it  would  eradicate 


28  PART   II.     ETIUWGY   Ol-    MALOCCLUSION 

to  a  considerable  extent  the  complex  ciucstion  of  diagnosis  and  treatment,  by  reduc- 
ing the  science  to  mathematical  and  mechanical  procedures,  while  the  practice  of 
dcnto-facial  orthopedia  would  require  no  artistic  ability  or  brain-racking  study  and 
anxiety.  We  would  then  ttnhesitatingly  place  the  teeth  of  every  case  in  normal 
occlusion,  and  if  teeth  were  missing,  we  would  open  the  spaces  and  insert  artificial 
teeth  to  maintain  normal  relations  and  arch  widths  of  the  denttires.  Especially 
in  the  treatment  of  children's  teeth,  without  a  single  thought  of  heredity  or  facial 
outlines  we  would  invariably  see  that  the  first  permanent  molars  were  placed  and 
retained  in  normal  disto-mesial  relations  so  that  the  dentures  would  be  guided  to  a 
normal  occlusion,  all  with  the  view,  as  this  false  teaching  asserts,  that  the  jaws  and 
even  all  the  bones  of  the  skull — since  there  would  be  no  such  things  as  inherited 
disharmonies — would  in  every  case  grow  to  harmonious  proportions  as  was  in- 
tended by  nature.  Fortunately  for  humanity,  nearly  all  competent  orthodontists 
of  today  are  following,  or  will  soon  follow,  in  their  practice,  the  more  rational  scien- 
tific teachings  abundantly  proven  by  experience  and  ethnologic  investigation. 
While  it  is  a  fact  that  a  very  large  proportion  of  malocclusions  arise  from  causes  of 
post-natal  origin,  it  is  equally  true  that  many  irregularities — from  simple  malposi- 
tions to  decided  antero-posterior  malrelations  of  the  dentures  and  jaws,  including 
every  variety  of  dento-facial  deformity — arise  through  the  same  channels  of  re- 
production that  produces  the  normal,  resulting  if  not  prevented,  in  exactly  that 
which  is  stamped  upon  them  by  the  laws  of  heredity  in  the  union  and  admixture  of 
harmonious  and  inharmonious  types. 

One  often  hears  and  sees  from  the  lips  and  pens  of  men  of  high  standing  in 
orthodontia  relative  to  causes  that  malocclusions  of  the  teeth  never  arise  from 
heredity,  but  always  from  post-natal  or  intra-viterine  local  causes,  which  follows 
the  erroneous  teaching  that  "all  persons  are  destined  by  nature  (or  through  in- 
heritance) to  have  normal  occlusions  of  the  dentures."  They  might  as  well  assert 
their  disbelief  and  consequent  ignorance  of  the  laws  and  principles  of  evolution,  of 
biology,  of  ethnology,  of  hybridism,  and  of  irregularities  in  all  parts  of  the  body 
which  everywhere  confront  us  in  offspring  and  that  are  plainly  seen  to  have  arisen 
through  direct  heredity,  and  from  unions  of  different  types.  Furthermore,  they 
must  also  assert  their  disbelief  in  the  commonly  known  results  in  artificial  cross- 
breeding in  both  plants  and  animals. 

The  laws  of  biology  teach  throixghout  the  entire  evolution  and  development  of 
all  living  things,  that  nature  does  not  "start  out  in  each  individual  to  build  a 
physically  or  esthetically  perfect  being,"  but  she  btiilds  that  which  is  forced  upon 
her  by  the  inexorable  laws  of  biologic  development,  with  the  result  that  dishar- 
monies in  the  sizes,  forms,  and  positions  of  the  teeth,  jaws,  and  all  bones  which 
characterize  physiognomies  are  quite  as  possible  and  even  much  more  liable  than 
esthetically  perfect  types.  It  must  be  remembered  that  within  the  domain  of 
normality,  the  physically  ideal  and  the  esthetic  is  a  rarity  and  not  the  rule.  Outside 
of  the  domain  of  what  is  eiToneouslv  called  the  "normal,"  but  bv  which  is  more 


CHAPTER   IV.     ETIOLOGIC  PRINCIPLES  29 

often  meant  the  typically  perfect,  nature  under  the  biologic  activities  of  heredity 
reproduces  in  the  offspring  in  some  form  that  which  is  impressed  upon  the  germ 
cells  by  progenitors. 

These  deeper  questions  of  heredity  cannot  be  appreciated  without  at  least 
a  superficial  understanding  of  the  laws  and  principles  of  biology  outlined  in 
Chapter  VI. 

It  is  not  strange  that  many  should  believe  and  teach  that  all  malocclusions 
of  the  teeth  arise  from  local  causes  when  it  is  seen  that  so  many  malpositions  of 
the  teeth  and  jaws  do  undoubtedly  arise  in  this  way,  and  these  moreover  are 
frequently  in  close  duplication  of  those  which  arise  from  heredity. 

Nor  is  it  strange  that  many  who  have  observed  the  remarkably  beneficial  eft'ects 
following  the  removal  of  adenoids  for  patients  of  inhibited  physical  and  mental 
development,  should  conceive  an  exalted  opinion  of  local  causes  and  the  power 
of  mechanical  stimulation  toward  bone  growth. 

The  rapid  beneficial  development  in  these  instances  is  no  doubt  due:  first,  to 
the  removal  of  the  cause,  withovit  which  little  could  be  accomplished,  and  second, 
the  consequent  renewal  of  natural  physiologic  activities  of  growth,  stimvilated 
secondarily  by  the  operation  itself,  and  its  improved  resultant  occlusion. 

There  can  be  no  doubt  from  a  scientific  standpoint  that  the  jaw  bones  proper 
—and  especially  the  mandible  which  is  not  svibjccted  to  the  same  influences  that 
retard  the  development  of  maxilla — assume  the  forms  and  sizes  determined  by  the 
unchangeable  laws  oi  heredity  under  healthy  growth  conditions  in  the  same  way  as 
other  bones  of  the  body.  While  the  rapidity  of  their  early  growth  may  be  hastened, 
and  while  inhibited  developments  may  be  stimulated  to  normal  growth,  and  while 
the  forms  of  the  bones  may  be  varied  slightly  by  bending,  it  is  contrary  to  the  laws 
of  biology  that  environing  forces,  or  any  kind  of  artificial  stimulation  has  the  power 
to  cause  them  to  grow  interstitially  larger  than  their  mherent  normal  size. 

It  would  be  far  more  advisable  in  early  childhood  cases  of  marked  disto-mesial 
malocclusion  of  the  buccal  teeth  which  are  not  distinctly  due  to  local  causes,  or  to 
retrusions  of  one  denture  or  the  other,  to  wait  for  a  more  mature  development  of 
the  facial  outlines,  which  would  enable  a  sure  and  correct  diagnosis  of  the  conditions, 
and  then  treat  the  case  along  the  lines  of  art  and  within  the  realms  of  physiologic 
demands. 


CHAPTER  V 

ETIOLOGIC   INFLUENCES   OF   DECIDUOUS   AND   ERUPTING   PERMANENT 
TEETH   WITH   PRINCIPLES   OF   TREATMENT 

One  of  the  most  prolific  of  the  local  causes  of  malocclusion  arises  through 
improper  care  and  treatment  of  the  deciduous  teeth.  A  large  proportion  of  the 
malocclusions  which  arise  from  this  cause  are  due  to  the  fact  that  parents  and  den- 
tists do  not  appreciate  the  imperative  importance  of  preserving  the  teeth  of  the 
temporary  dentures  up  to  the  very  moment  when  each  succeeding  permanent  tooth 
is  ready  to  erupt;  and  they  also  fail  to  understand  the  character  of  influences  which 
are  exerted  by  the  premature  loss  of  one  or  more  of  these  teeth  toward  marring  the 
positions  and  occlusion  of  the  permanent  teeth. 

The  errors  of  dentists  in  this  field  of  their  profession  are  so  frequent  and 
so  serious  it  would  seem  that  there  is  a  thoughtless  disregard  of  principles 
which  are  plainly  shown  in  the  natiu-al  physiologic  processes  of  secondary  den- 
tition, and  which  no  thinking  mind  can  contemplate  without  amazement  and 
admiration. 

In  view  of  the  large  amount  of  literature  vipon  this  subject,  and  the  competent 
teaching  in  the  various  colleges,  showing  the  importance  of  preserving  the  decid- 
uous teeth,  it  would  seem  that  we  should  be  free  from  those  conditions  which 
frequently  confront  us,  and  which  must  be  regarded  as  caused  by  a  ruthless  inter- 
ference with  one  of  nature's  most  important  provisions. 

The  deciduous  teeth  are  most  evidently  for  the  purpose  of  affording  means 
of  mastication  during  the  early  years  when  the  full-sized  permanent  teeth  would  be 
all  out  of  proportion  in  size  and  appearance  for  the  tindeveloped  jaws  and  features. 
They  are  there  also  for  the  purpose  of  giving  nature  an  opportunity  to  develop  and 
erupt  the  permanent  teeth,  and  in  bringing  them  forward  in  successive  and  sys- 
tematic stages,  timed  according  to  the  needs  of  general  growth  and  use.  They  are, 
moreover,  for  the  purpose  of  establishing  occlusal  relations  of  the  permanent  teeth 
and  harmonious  relations  of  the  facial  outlines. 

At  about  five  years  of  age  the  first  permanent  molars  commence  to  crowd 
their  way  into  the  arches  between  the  bases  of  the  deciduous  arches  on  one  side,  and 
the  rami  and  tuberosities  on  the  other.  Nature,  apparently  conscious  of  the  force- 
ful influences  of  this  eruptive  process  toward  an  interstitial  forward  movement  of 
the  entire  deciduous  dentures,  has  provided  the  deciduous  molars  with  broad 
spreading  roots  so  as  to  take  a  sufficiently  firm  and  immovable  hold  of  their  sur- 
roundings to  successfully  combat  this  force,  in  the  same  way  that  will  be  found  with 
the  roots  of  trees  which  are  subjected  to  the  force  of  strong  winds.    Note  also  how 

30 


CHAPTER    V.     DECIDUOUS  AXD  ERUPTIXG  PERMANENT   TEETH  31 

perfectly  nature  under  normal  conditions  has  timed  this  eruptive  stage  to  prevent 
that  possibility  which  she  so  evidently  fortifies  herself  against,  and  at  the  same  time 
to  take  advantage  of  the  general  developing  forces  of  eruption.  Under  the  needs 
of  increasing  age  for  greater  masticating  facilities,  she  starts  the  eruption  of  the 
first  permanent  molars  at  a  time  when  the  strong  phalanx  of  the  deciduous  denture 
is  there,  or  should  be  there,  to  resist  the  forward  pressure  of  these  erupting  teeth ; 
nor  does  she  commence  it  before  there  is  nearly  enough  room  by  growth  for 
those  large  teeth  back  of  the  temporary  set;  nor  before  the  alveolar  surroundings 
of  the  deciduous  roots  are  developed  to  comparative  stability;  nor  does  she  wait 
until  the  temporary  molar  roots  have  become  weakened  by  resorption  from  the 
eruptive  forces  of  the  premolars. 

What  could  be  more  prophetic  than  these  provisional  acts  on  the  part  of  nature 
in  emphasizing  the  importance  of  preserving  the  natural  relative  position  of  the 
bases  of  the  deciduous  arches  in  order  that  the  permanent  molars  which  are  destined 
to  establish  the  occlusal  relations  of  the  adjoining  permanent  buccal  teeth  will  not 
be  allowed  to  drift  forward  of  their  natural  positions,  since  it  is  upon  the  estab- 
lished position  of  the  first  permanent  molars  that  the  relative  positions  of  adjoining 
buccal  teeth  are  dependent,  and  also  the  final  occlusion  and  dento-facial  relation 
of  all  the  teeth.  From  this  we  may  draw  a  lesson  of  the  importance  of  pre- 
serving these  temporary  piers  to  the  future  arches  imtil  the  time  of  the  eruption 
of  their  successors,  because  at  whatever  stage  the  arch  is  long  deprived  of  their 
support,  the  permanent  molars  will  surely  tend  to  drift  forward  to  fill  the 
gaps,  notwithstanding  the  restraining  influences  of  perfect  interdigitating  occlud- 
ing cusps. 

Another  of  nature's  acts  along  this  line  is  worthy  of  the  deepest  consideration, 
because  it  seems  to  be  prophetic  of  the  apparently  recognized  tendency  of  the  per- 
manent molars  to  drift  forward,  and  of  the  importance  of  preventing  it  up  to  the 
last  moment.  In  the  typically  normal  processes  of  secondary  dentition,  when  the 
second  deciduous  molars  are  thrown  off,  the  second  premolars  are  ready  to  prick 
through  the  overlying  gum  tissue,  and  soon  take  their  places  in  preserving  the 
integrity  of  the  arch.  This  is  another  reason  for  the  spreading  of  the  deciduous 
roots  in  order  that  the  resorptive  forces  of  eruption  may  have  an  opportunity,  with- 
out the  necessity  of  extraction,  to  make  a  place  beneath  for  the  premolar  crowns, 
and  thus  permit  them  to  erupt  as  much  as  possible  up  to  the  last  moment  of  their 
power  to  hold  the  required  space  open.  Otherwise,  as  is  frequently  seen — especially 
on  the  lower — the  second  premolars  are  impacted  in  the  dovetailing  inclination  of 
adjoining  teeth,  because  of  the  premature  extraction  or  loss  by  decay  of  the  second 
deciduous  molars.  It  may  be  that  this  is  one  reason  why  the  second  premolars 
are  the  only  ones  of  the  permanent  dentures  which  occupy  less  space  than  the 
deciduous  teeth  that  precede  them  in  order,  perhaps,  that  they  may  have  a  little 
better  chance  to  get  into  place  before  the  drifting  tendencies  of  the  adjoining  teeth 
can  shut  them  out. 


32  ['ART   JI.     ETIOLOGY  OF   MALOCCLUSION 

Malerdption  of  Labial  Teeth 

From  five  to  six  years  of  age  under  normal  processes,  the  arches  commence  to 
expand  in  the  incisal  area  in  co-ordination  with  the  erupting  forces,  and  from  six  to 
seven  years  of  age,  the  roots  of  the  temporary  central  incisors  are  so  completely 
resorbed  that  the  crowns  fall  out  or  are  forced  out  by  the  erupting  permanent  cen- 
trals. As  these  teeth  prick  through  the  gums,  the  cutting  edges  are  commonly  in 
front  of  the  deciduous  line,  and  are  not  uncommonly  malturned.  Their  disto-mesial 
widths  are  so  much  greater  than  the  deciduous  centrals,  that  notwithstanding  the  ex- 
pansion of  the  arches  there  is  usually  not  sufificient  room  between  the  deciduous 
laterals  for  their  perfect  alignment  at  this  time.  This  has  frequently  led  to  the 
premature  extraction  of  the  deciduous  laterals  under  the  false  impression  that  they 
were  causing  a  permanent  irregularity  of  the  centrals.  Whereas,  in  this  very  act 
one  of  the  important  physiologic  forces  of  nature — the  eruptive  force — for  the  ex- 
pansion of  the  arches  is  stopped.  The  forces  of  growth  are  far  greater  than  we  are 
accustomed  to  imagine ;  nor  can  it  be  apprecia,ted  fully  unless  one  has  observed  the 
power  which  the  growth  of  the  roots  of  trees  exert  which  extend  under  strongly 
imbedded  cement  sidewalks,  and  which  will  often  break  the  cement  blocks  and  raise 
them  several  inches.  With  the  extraction  of  the  deciduous  laterals,  and  the  growth 
of  the  arch  inhibited,  there  is  soon  found  to  be  far  less  than  sufificient  room  for  the 
permanent  latei"als,  and  this  leads  to  the  premature  extraction  also  of  the  deciduous 
cuspids,  followed  by  an  alignment  of  the  laterals  which  partially  fill  the  cuspid 
spaces.  Soon  after  this,  or  at  about  eight  or  Tiine  years  of  age,  the  first  upper  pre- 
molars erupt,  taking  the  places  of  the  first  deciduous  molars.  If  the  deciduous 
cuspids  are  not  there  they  naturally  drift  forward  to  partially  fill  the  distal  portion 
of  the  cuspid  spaces,  with  the  tendency  also  for  the  teeth  back  of  these  to  drift 
forward,  so  that  when  it  is  time  for  the  cuspids  to  ervipt,  there  being  no  room,  or  not 
sufificient  room  for  them,  they  are  obliged  to  force  their  way  through  the  gums 
above  their  proper  places,  where  they  have  often  been  regarded  by  many  ignorant 
people  as  unnatural  "tusks,"  and  have  frequently  been  wrongfully  extracted  by 
dentists  as  the  shortest  if  not  the  best  means  of  correcting  a  deforming  irregularity, 
which  has  seemed  to  them  impossible  to  connect  properly  in  any  other  way.  See 
"Question  of  Extraction,"  Chapter  XII,  and  "Maleruption  of  Cuspids,"  Class  I. 

Next  in  importance  to  the  preservation  of  the  deciduous  second  molars  is  the 
retention  of  the  deciduous  cuspids  up  to  the  last  moment  of  their  usefulness,  what- 
ever the  apparent  irregularity  of  the  incisors ;  and  while  the  permanent  cuspids  are 
very  much  wider  than  the  space  occupied  by  the  deciduous  cuspids  their  wedge-like 
form  impelled  by  the  forces  of  eruption  and  natural  provisional  enlargement  of 
the  jaws,  will  usually  enable  them  to  take  their  places  in  normal  alignment. 

Another  cause  of  the  maleruption  of  cuspids  is  the  premature  loss  of  the  first 
or  second  deciduous  molars,  which  not  only  inhibits  the  growth  development  of 
the  arch  in  that  area,  but  permits  a  mesial  movement  of  the  first  permanent  molars 
which  are  forced  forward  by  the  oncoming  erupting  second  molars.    The  premolars 


CHAPTER    V.     DECIDUOUS   AND  ERUPTING  PERMANENT   TEETH  33 

having  also  been  forced  to  a  mesial  malposition,  the  cuspids  are  forced  to  erupt  out 
of  alignment ;  especially  if  the  deciduous  cuspids  have  been  prematurely  extracted 
as  frequently  occurs  in  this  condition,  to  give  room  for  the  eruption  of  the  premolars. 

The  maleruption  of  lower  cuspids  is  not  so  frequent  as  the  upper  cuspids.  One 
of  the  reasons  for  this  is :  the  lower  permanent  cvispids  erupt  before  the  first  pre- 
molars, and  consequently  are  not  so  liable  to  be  interfered  with.  However,  if 
the  first  molars  are  forced  forward  of  their  normal  positions  by  the  erupting  and 
fixed  mesial  malposition  of  the  second  permanent  molars,  the  cuspids  are  the  ones 
which  are  forced  out  of  alignment  whatever  their  position  or  stage  of  eruption.  One 
can  see  by  the  many  causes  direct  and  indirect,  which  so  frequently  arise,  why  it  is 
that  the  irregularity  that  is  characterized  by  maleruption  of  cuspids,  is  one  of  the 
most  common  of  all  the  malocclusions. 

By  far  the  larger  proportion  of  temporary  denttu'es  are  in  normal  occlusion  and 

in  correct  dento-facial  relations  according  to  age  and  type,  because  that  is  the 

dominant  type  toward  which  the  natural  biologic  forces  tend.    And  were  it  not  for 

maltreatments  and  certain  local  and  constitutional  causes,  there  would  be  a  far 

greater  number  of  cases  than  at  present  that  would  attain  to  a  normal  occlusion  of 

the  teeth. 

Thumb-Sdcking 

The  one  cause  which  most  often  affects  the  normal  relations  of  the  deciduous 
dentures  is  the  habit  of  thumb-sucking,  which  if  allowed  to  continue  into  the  early 
years  of  secondary  dentition  will  frequently  produce  all  the  dento-facial  character- 
istics of  an  upper  protrusion,  but  with  no  effect  upon  the  disto-mesial  relations  of 
the  buccal  teeth,  except  to  narrow  the  arches. 

The  modus  operandi  of  the  cause,  its  correction,  and  final  treatment  of  the 

resultant  malocclusion,  will  be  found  in  the  Practical  Treatment  of  Division  1, 

Class  I. 

Influences  of  Heredity  upon  Deciduous  Dentures 

In  regard  to  the  malocclusions  which  arise  from  heredity,  from  the  simplest 
to  the  most  pronounced  dento-facial  deformities,  it  is  somewhat  rare  that  the  decid- 
uous dentures  and  jaws  indicate  in  an  appreciable  degree  the  condition  which  is 
destined  to  affect  the  permanent  teeth  and  more  mature  jaws.     This  is  because 

inherited  phvsical  dental  malformations 

Fi(,.  1. 

rarely  commence  to  develop  before  the 
beginning  of  secondary  dentition,  nor 
are  they  often  sufficiently  pronounced 
to  become  apparent  before  the  period  of 
adolescence. 

While  there  are  exceptions  to  this 
rule  which  is  illustrated  by  Fig.  1 ,  show- 
ing the  plaster  models  of  the  deciduous 
and  the  permanent  dentures  of  a  Class 


34  T'.lA'r   //.     ETfOLOUV  OF   MALOCCLUSION 

IT  case  at  five  and  eleven  years  of  age,  it  is  nevertheless  true  that  early  intpr- 
fereiicc  ivitJi  the  temp>orary  dentures,  such  as  exj)(ii!(ling  the  arches,  or  the  dislo-mesial 
shiftiiiii  of  orrhisdl  relations,  is  nirely  advisable,  unless  one  is  sure  that  the 
threatened  condition  has  ariscMi  from  some  definite  local  cause  which  the  natural 
phvsiologie  processes  of  nature  will  not  correct.  If  teeth  are  prematurely  lost, 
threatening  maleruption  or  crowded  malalignments,  the  areas  should  be  properly 
expanded  and  retained  for  the  free  eruption  of  the  succeeding  teeth.  But  under 
other  circumstances  where  the  erupting  permanent  teeth  do  not  seem  to  have 
sufficient  room  and  are  forced  into  overlapping  malalignments — a  condition  quite 
common  with  the  lower  incisors — it  should  be  remembered  that  this  is  the  only 
way  in  which  nature  is  enabled  to  get  those  large  teeth  into  the  small  and  as 
yet  undeveloped  jaws  which  she  is  rapidly  enlarging  by  interstitial  growth  for 
that  purpose.  If  left  to  herself  as  she  has  been  during  all  past  ages  when  the 
same  character  of  activities  has  repeatedly  presented  itself  with  results  that  were 
nearly  if  not  quite  invariably  normal,  there  is  no  reason  to  believe  that  the  same 
results  would  not  now  obtain  without  artificial  interference.  Besides,  anyone  of 
long  experience  has  seen  any  number  of  these  decided  cases  of  overlapping  mal- 
alignments of  the  erupting  permanent  teeth  fully  right  themselves  through  natural 
forces  alone. 

It  is  therefore  not  always  necessary  or  advisable  to  attempt  any  artificial  pre- 
paration for  the  eruption  of  the  permanent  teeth;  nor  is  it  always  advisable  to 
begin  at  a  very  early  age  the  regulation  of  children's  permanent  teeth,  except  in 
those  cases  in  which  the  eft'ects  of  a  local  cause  still  remain  that  cannot  be  corrected 
by  natural  forces. 

It  may  be  that  the  habit  of  thuml)-sucking  has  narrowed  the  arches  and  pro- 
truded the  upper  incisal  area  and  retruded  the  lower,  or  that  the  injudicious  ex- 
traction or  premature  loss  of  the  deciduous  teeth  has  inhil)ited  the  growth  develop- 
ment, and  contracted  the  spaces  required  for  the  aligned  eruption  of  the  permanent 
teeth,  or  it  may  be  that  it  is  one  of  the  many  threatening  malocclusions  which  arise 
from  adenoids  or  nasal  stenosis.  Under  such  conditions,  the  early  regulation  of 
children's  teeth  is  always  admissible  and  advisable,  and  should  be  accomplished  with 
the  most  delicately  constructed  appliances  for  both  movement  and  retention. 
Furthermore,  there  should  be  a  definite  understanding  with  the  parents  that  the 
operation  is  intended  to  place  only  the  ervipted  teeth  in  corrected  positions,  for  the 
purpose  of  permitting  the  free  eruption  of  the  remaining  permanent  teeth. 

One  of  the  greatest  objections  to  the  early  regulation  of  children's  teeth,  is 
that  we  usually  have  them  on  our  hands  up  to  and  through  the  eruption  of  the  sec- 
ond molars,  while  the  little  ones  vip  to  nine  or  ten  years  of  age  could  be  running 
free  and  building  up  stable  conditions  of  future  health;  moreover,  the  operation 
in  many  instances  could  1  )e  far  more  easily  accomplished  for  everyone  concerned 
by  commencing  after  the  erviption  of  the  premolars — except  of  course  in  those 
cases  where  simple  demands  are  imperative. 


CHAPTER    V.     DECinrorS   AXD  ERVPTIXG   PERMANENT   TEETH  35 

Another  phase  of  this  branch  should  not  be  forgotten:  It  has  reference  to  the 
early  disto-mesial  malrelation  of  the  first  permanent  molars  whose  correction  must 
be  determined,  as  before  explained,  by  the  character  of  the  cause.  If  seen  to  be 
purely  local,  correct  by  all  means,  but  do  not  be  in  haste  to  correct  if  there  is 
any  doubt  that  the  cause  may  be  an  inherited  protrusion,  upper  or  lower.  The 
student  is  referred  to  fuller  explanation  of  this  phase  in  Chapter  XXI. 

A  Local  Cause  of  Protrusions 

Before  leaving  the  subject  of  secondary  dentition,  one  of  its  greatest  lessons 
cannot  be  too  often  repeated.  This  relates  to  that  large  majority  whose  permanent 
teeth  are,  or  would  have  been,  normal  in  occlusion  and  dento-facial  relations 
in  all  instances  had  the  deciduous  teeth  been  preserved,  or  retained  according  to 
nature's  requirements.  With  these  naturally  normal  conditions,  if  the  loss  of  decid- 
uous teeth  has  permitted  the  permanent  buccal  teeth  to  drift  forward,  ever  so 
slightly,  from  an  otherwise  normal  dental  and  facial  relation  in  the  arch,  and  the 
front  teeth  then  erupt  in  alignment,  an  ahuornial  protrusion  of  the  facial  outlines 
will  be  exactly  in  proportion  to  this  movement.  If  the  extent  of  this  mesial  movement 
is  suflficient  to  carry  the  crests  of  the  cusps  in  front  of  those  of  the  occluding  teeth, 
a  full  mesial  malinterdigitation  of  the  upper  cusps  is  inevitaljlc.  This  shows  how 
from  premature  extraction,  or  unnecessary  loss  of  deciduous  teeth  alone,  protrusion 
of  the  permanent  teeth  may  arise,  and  though  in  amount  it  but  slightly  changes  the 
facial  contour,  it  may  be  sufficient  to  mar  the  expression  of  an  entire  physiognomy. 
When  this  occurs  with  both  upper  and  lower  denttires,  as  at  times  it  no  doubt 
does — all  of  the  teeth  having  been  forced  forward  of  their  normal  position,  and 
with  a  possible  preservation  of  normal  occlusion  and  alignment — it  is  a  most  un- 
fortunate affair,  because  people  in  general,  and  among  them  dentists  of  renowned 
ability  in  orthodontia,  seeing  these  perfect  conditions  of  normal  occlusion,  inter- 
pret the  facial  imperfections  which  have  resulted  from  this  local  cause,  as  inherent, 
or  one  intended  by  nature,  and  as  perfect  as  it  is  possible  for  that  individual. 

We  hardly  imagine  that  in  the  many  faces  we  meet,  there  has  occurred  during 
their  childhood  days  a  thoughtless  or  ignorant  disregard  of  important  principles 
in  the  treatment  of  the  deciduous  teeth,  which  has  resulted  in  an  unnatural  and 
unnecessary  protrusion  of  the  permanent  teeth,  slight  or  great,  over  the  upper  or 
entire  dento-facial  area,  characterizing  the  features,  producing  unesthetic  expres- 
sions, and  marring  those  perfect  facial  outlines  which  nature  would  have  produced 
had  she  been  permitted,  or  aided  in  having  her  way. 

Comparison  of  Childhood  and  Adult  Physiognomies 

The  common  normal  peculiarity  of  childhood  physiognomies,  between  the  ages 
from  six  to  twelve,  is  that  of  a  slight  protrusion  of  the  upper  and  lower  lips  in 
relation  to  the  other  undeveloped  features.  By  association,  we  intuitively  and 
unconsciously  accept  this  appearance  in  late  childhood  and  early  youthhood  with- 


36  J'.IRT   II.     ETIOLOGY   OF   MALOCCLUSIOX 

out  a  tliovigliL  of  l'iici;il  iinperfcction.  And  yet  were  we  to  analyze  the  facial  out- 
lines of  these  young  people  from  the  artistic  viewpoint  of  the  adult  perfect  outlines, 
we  would  find  that  a  larj^e  proportion  are  similar  to  those  which  if  seen  in  adult  life 
would  be  truthfully  denominated  bimaxillary  protrusion. 

This  is  due  to  the  fact  that  the  teeth  are  the  only  bones  in  the  body  which 
do  not  grow  larger  than  their  first  formations;  and  therefore  during  the  development 
and  eruption  of  the  adult-sized  permanent  teeth  in  the  small  jaws  of  childhood, 
where  they  are  crowded  in  one  upon  the  other,  in  their  different  stages  of  develop- 
ment, they  necessarily  expand  the  dental  and  alveolar  arches  prematurely,  during 
the  stage  of  secondary  dentition ;  and  as  the  entire  maxillary  and  other  facial  bones 
do  not  keep  pace  with  this  rapid  development,  the  lips  are  unesthetically,  though 
naturally,  forced  forward  in  their  outlines — all  of  which  the  ultimate  growth  of 
other  parts  finally  harmonizes. 

By  continued  observation  of  the  development  of  childhood  and  adolescent 
features,  one  will  frequently  see,  even  as  late  as  twelve  years  of  age,  prominent 
mouths  and  apparent  receding  chins,  that  at  seventeen  or  eighteen  years  of  age 
will  entirely  disappear.  This  goes  to  prove  that  which  the  author  has  endeavored 
to  emphasize  in  other  chapters,  that  the  bones  which  characterize  physiognomies 
do  not  always  begin  to  show  at  twelve  years  of  age  that  which  is  destined  by  the 
dominant  strains  of  heredity  to  characterize  the  featvires  during  later  adolescence. 

The  author  remembers  a  mate  of  his  school  days  who  at  twelve  years  of  age 
was  smaller  than  the  other  boys,  with  effeminate  features  and  small  nose  like  his 
mother's,  but  who  at  twenty  years  of  age  was  six  feet  tall  with  large  angular  strong 
featvires  and  prominent  Roman  nose  like  his  father's  more  dominant  type. 


CHAPTER   \T 

LAWS    OF    BIOLOGY    REGARDED   AS   ETIOLOGIC    FACTORS   IN   MALOCCLUSION 

General  Principles  of  Biology. — Before  proceeding  to  a  study  of  those  maloc- 
clusions which  arise  partly,  and  to  a  large  extent  from  some  form  of  heredity,  it  is 
important  for  the  student  to  be  informed  in  regard  to  the  general  laws  of  biology 
upon  which  is  dependent  the  entire  scientific  basis  of  that  which  pertains  to  this 
branch  of  our  subject,  so  that  he  may  have  a  more  intelligent  appreciation  of  the 
various  propositions  presented  along  this  line. 

The  science  of  biology  lies  at  the  very  foundation  of  all  knowledge  pertaining 
to  living  things — their  origin,  development,  propagation,  and  all  co-ordinating 
and  environing  influences.  Unfortunately,  the  principles  of  biology  and  general 
evolution  are  quite  commonly  regarded,  even  by  people  who  pride  themselves  upon 
their  education,  as  of  no  more  practical  value  than  the  sciences  of  astronomy  and 
geology;  whereas,  there  is  no  branch  of  learning  which  enters  so  intimately  and 
extensively  into  other  branches  that  are  regarded  as  the  essentials  of  life  and 
education. 

While  this  is  particularly  true  in  the  general  practice  of  medicine  and  den- 
tistry, there  is  no  branch  in  which  the  laws  and  principles  of  biology  are  of  such 
importance  as  in  the  study  of  the  causes  and  treatment  of  malocclusion  and  dento-- 
facial  disharmonies,  because  they  present  an  authentic  foundation  for  a  broader 
understanding  and  application  of  the  possibilities  of  ethnologic  influences  in  the 
admixture  of  different  types  of  races,  and  in  the  union  of  physical  disharmonies 
everywhere.  Therefore,  a  brief  epitome  of  biologic  laws  seems  essential  to  an  intel- 
ligent comprehension  of  certain  principles  which  enter  so  largely  into  the  etiology 
of  malocclusions.  It  is  hoped,  moreover,  that  this  will  stimulate  students  to  a  more 
extensive  study  of  this  important  branch  of  literatvire. 

Biology  and  biologists  deal  only  with  the  natural  laws  of  organic  evolution. 
By  long,  patient,  and  scientific  investigation,  biologists  verify  every  proposition 
over  and  over  again  before  it  is  stated  as  a  scientific  truth.  These  pertain  principally 
to  the  problems  of  life,  heredity,  variation,  natural  selection,  and  influences  of 
environment. 

Every  anatomic  form  or  structure — barring  inhibited  development — which 
arises  from  the  Law  of  Heredity  is  laid  down  in  the  rhetabolic  activities  of  the 
germ  cells  at  the  time  of  fertilization  and  forced  upon  the  oft'spring  by  the  laws  of 
reproduction. 

Fortunately,  there  is  another  law  which  is  cjuite  as  important  in  V:iiologic  develop- 
ment as  the  law  of  heredity.    This  is  the  law  of  Natural  Variation  which  also  lays 

37 


38  IWRT   II.     ETIOLOGY   OF   MALOCCLUSION 

down  in  the  germ  cells  the  (elemental  beginnings  of  variations  which  arise  in  the 
offspring  that  dift'er  from  the  parental  stock  and  like  those  of  heredity  are  capable 
of  being  propagated  to  future  generations. 

The  other  two  laws.  Natural  Selection  and  Environment  may  be  said  to  act 
extrinsically — the  one  being  nature's  selection  of  those  whose  qualities  are  best 
adapted  to  the  environment  and  propagation  of  their  kind;  and  the  other  deals 
purely  with  adaptive  variations  in  structure,  etc.,  which  fits  them  a  little  better  to 
live  and  thrive  in  the  environment  into  which  they  are  thrown. 

This  presents  two  important  truths:  First,  no  physical  form  or  variation  in 
anatomic  structure  can  arise  except  through  the  channel  of  the  germ  cells,  though 
the  environing  influences  upon  already  endowed  properties  of  the  individual  after 
birth  may  result  in  a  more  adaptive  degree  of  development.  Second,  it  shows  the 
impossibility  of  appreciably  increasing  the  inherited  sizes  or  forms  of  any  of  the 
bones  by  local  or  environing  stimulation. 

Heredity 

The  Law  of  Heredity  is  that  which  determines  the  propagation  of  physical 
forms,  structures,  peculiarities,  and  even  traits  of  character.  Its  importance 
along  these  lines  is  clearly  related  by  J.  Arthur  Thomson,  of  Aberdeen,  in  his  recent 
book,  "Heredity."  "There  are  no  scientific  problems  of  greater  human  interest 
than  those  of  Heredity ;  that  is  to  say  the  genetic  relation  between  successive  gene- 
rations. Since  the  issues  of  individual  life  are  in  great  part  determined  by  what  the 
living  creature  is,  or  has  to  start  with,  in  virtue  of  its  hereditary  relation  to  parents 
and  ancestors,  we  cannot  disregard  the  facts  of  heredity  in  our  interpretation  of  the 
past,  our  conduct  in  the  present,  or  our  forecasting  of  the  future." 

Those  who  have  not  given  much  thought  to  the  subject  of  heredity  are  accus- 
tomed to  think  only  of  direct  heredity,  or  the  inheritance  of  some  physical  pecu- 
liarity or  characteristic  which  had  its  existence  in  one  of  the  parents;  whereas, 
this  is  only  one  of  the  many  forms  of  heredity.  It  may  be  a  blending  or  composite 
union  of  quite  distinctively  different  features  or  family  types  belonging  to  both 
parents  harmoniously  or  disharmoniously  united  in  the  off'spring;  or  it  may  be  that 
the  undiluted  forms  or  features  of  one  parent  will  be  found  closely  associated  in  the 
offspring  with  the  characteristic  features  of  the  other  parent,  as  the  large  nose, 
ears,  jaws,  or  teeth  of  one  parent  in  connection  with  the  smaller  and  more  delicate 
features  of  the  other  parent. 

How  often  do  we  see  beautiful  children  from  homely  parents,  because  of  the 
transmission  to  the  child  of  those  special  features  of  the  two  physiognomies  that 
harmonize  in  union?  On  the  other  hand,  how  often  do  we  see  plain  and  homely 
children  from  parents  whose  physiognomies  individually  are  symmetrical  and 
attractive,  because  of  the  transmission  to  the  child  of  a  combination  of  the  features 
of  both,  which  being  dissimilar  in  size  are  inharmonious  in  vmion?  And  as  the  os- 
seous framework  is  the  principal  medium  that  characterizes  the  various  forms,  even 


CHAPTER    VI.     LAWS  OF   BIOLOGY  39 

the  large  teeth  of  one  parent  and  the  small  jaws  of  the  other — though  never  claimed 
as  more  than  a  rare  occurrence — will  probably  continue  to  be  placed  among 
the  causes  of  irregularities  by  intelligent  dentists,  especially  as  it  can  be  so  easily 
verified. 

The  condition  in  question  may  be  some  physical  or  mental  peculiarity  which 
had  no  existence  in  either  parent,  but  w'hich  obtained  in  some  more  distant  fore- 
bear. This  atavistic  heredity  may  have  passed  without  recurrence  through  many 
generaticMis,  to  suddenly  crop  out  in  the  offspring  without  any  apparent  known 
cause;  or  it  may  have  arisen  from  an  exceedingly  complicated  propagation  under 
the  forces  of  natural  sexual  selections,  similar  to  that  which  is  produced  by  arti- 
ficial selection  or  hybridizing,  demonstrated  Ijy  what  has  been  achieved  in  the  past 
in  regard  to  horses,  cattle,  poultry,  pigeons,  fruits,  flowers,  etc. 

Among  the  vast  number  of  trial  and  experimental  efforts  along  this  line,  there 
has  been  discovered  a  number  of  almost  unbelievable  laws  of  heredity  which  are  as 
dependable,  when  the  exact  requirements  are  fulfilled,  as  direct  heredity.  One  of 
these  is  known  as  "Mendel's  Law."  A  further  consideration  of  the  sul)ject  of  hered- 
ity in  its  various  phases  and  practical  application  to  diagnosis  and  treatment  of 
malocclusion,  will  be  found  in  other  chapters. 

Natural  Variation 

Next  in  importance  to  the  laws  of  Heredity  is  the  law  of  Natural  Variation, 
without  which  everything  would  have  repeated  itself  from  the  start,  and  conse- 
quently there  would  have  been  no  science  of  biology  or  organic  evolution.  One  of 
the  stable  peculiarities  of  all  living  structures  is  the  production  of  variations  in 
otherwise  original  hereditary  forms  and  characteristics.  These  natural  variations 
which  innumerably  arise  in  all  living  things  are  commonly  very  slight,  varying  in 
degree  from  the  almost  indiscernible  to  marked  or  anomalous  modifications  from 
the  typical  or  inherited  type.  All  natural  variations  invariably  arise  during  the 
metabolic  activities  of  the  germ  cells  in  both  plants  and  animals,  and  when  once 
started  are  under  the  same  transmissible  laws  of  heredity  as  those  of  the  established 
lines  of  heredity;  the  difterence  being  the  latter  are  not  so  likely  to  become  extinct 
because  of  their  established  adaptability  to  environment ;  whereas,  natural  varia- 
tions are  quite  likely  to  be  unnecessary,  or  opposed  to  their  environment,  and, 
therefore,  not  being  stimulated  toward  continued  de\'elopment  soon  die  out  in 
future  generations.  On  the  other  hand,  the  variation  may  be  one  which  more 
perfectly  fits  the  individual  for  the  struggle  of  life  and  a  higher  adaptation  to  the 
requirements  of  environment.  In  this  event,  the  variation  becomes  one  of  the  stable 
forms  of  heredity,  along  with  other  variations  which  have  arisen  in  the  same  way, 
thus  fulfilling  the  highest  function  of  this  particular  law  in  the  great  work  of  evolu- 
tion, and  in  the  development  of  species. 

Natural  variations  which  begin  with  or  are  inherited  by  the  individual  are  quite 
as  likely  to  be  in  disharmony  as  in  harmony  with  progressive  development.     The 


40  PART   II.     ETIOUXiV   Of   MALOCCLUSION 

difference  being  that  those  which  are  contrary  to  the  needs  of  hfe  are  not  as  capable 
or  as  prolific,  and  consequently  die  out. 

It  may  be  well  to  state  that  the  law  of  natural  variation  has  no  reference  in 
biology  to  perceptible  physical  changes  in  structure  that  arise  or  that  may  be 
produced  in  individuals  from  the  adaptive  forces  of  environment,  or  from  local 
causes,  or  any  form  of  artificial  stimuli.  All  forces  which  arise  from  extrinsic  causes 
have  little  or  nothing  to  do  with  biology  proper,  because  that  kind  of  variation  is 
not  transmissible,  except  when  the  cause  and  its  results  obtain  through  many  gene- 
rations so  as  to  finally  become  a  natural  variation. 

Moreover,  physical  growth  enlargements  or  "bone  growths,"  which  are  caused 
from  extrinsic  forces,  other  than  those  which  arise  after  inhibited  developments 
through  a  revivification  of  functional  activities,  are  never  of  a  normal  structural 
character,  and  certainly  never  result  in  healthy  interstitial  growth  of  the  bones 
to  the  extent  of  carrying  their  development  to  a  larger  than  their  inherent  size 
or  form.  This  assertion  is  made  advisedly,  basing  it  on  the  opinions  which  have 
recently  been  obtained  from  some  of  the  most  advanced  authors  and  teachers  of 
biology,  and  which  hardly  accord  with  the  somewhat  recent  propaganda  promul- 
gated by  certain  orthodontic  teachers  relative  to  the  fantastic  possibilities  of  "bone 

growth . ' ' 

Natural  Selection 

Darwin's  law  of  Natural  Selection  is  not,  as  is  popvilarly  supposed,  the  selection 
of  mates  through  instincts  and  qualities  of  the  individual,  or  sexual  selection,  but 
it  is  that  which  was  intelligently  stated  by  Huxley  when  he  invented  the  term 
"survival  of  the  fittest," — in  other  words,  nature's  selection  of  those  who  are 
best  fitted  for  thriving  and  procreating  their  kind  amid  the  environment  into  which 
they  are  thrown. 

When  individuals  in  plant  or  animal  life  are  forced  to  exist  amid  environment 
in  which  they  are  not  physically  adapted,  or  are  under  destructive  influences,  against 
which  they  are  not  fully  protected,  they  gradually  diminish  and  die  out;  though 
adaptive  natural  variations  may  arise  in  certain  of  the  oft'spring,  similar  to  adaptive 
artificial  variations  which  are  forced  to  arise  in  crossbreeding  and  which  tend  to 
restore  the  species  to  the  possibilities  of  progression. 

Environment 

In  the  struggle  of  life,  the  influences  of  Environment  are  exerted  very  strongly 
upon  each  individual  toward  the  production  of  adaptive  qualities  and  variations 
in  form,  to  render  them  more  fitted  for  sustaining  their  lives  amid  the  surroundings 
into  which  they  are  forced.  Whole  libraries  have  been  written  upon  this  phase  of 
biology  alone,  but  in  all  these  volumes  adaptive  variations  induced  to  arise  in  the 
individual  after  birth  are  rarely  considered  as  factors  in  biologic  development, 
because,  as  stated  before,  they  are  not  transmissible,  and  certainly  one  finds 
nothing  in  regard  to  the  possibility  of  producing  adaptive  or  harmonizing  physi- 


CHAPTER   VI.    LAWS  OF  BIOLOGY  41 

cal  growths  in  the  framework  of  animals  after  birth  by  mechanical  or  any  other 
stimuli,  because  biologists  are  engaged  with  problems  of  natural  reproduction  and 
development. 

Such  variations  in  the  individual  are  seen  at  times  in  plants  whose  roots  and 
limbs  reach  out  after  moisture  and  sunlight,  but  rarely  if  ever  in  animal  life;  except 
perhaps  in  superficial  tissues,  with  no  effect  upon  the  framework  or  skeleton, 
except  in  instances  of  inhibition,  resulting  in  diminished  growth.  What  does 
occur  and  through  the  forces  of  which  all  the  various  forms  of  life  and  species  have 
sprung,  is:  an  offspring  appears,  among  the  many,  with  a  natural  or  an  inherited 
variation,  perhaps  induced  in  fertility  by  the  stimulation  of  needs  which  surround 
the  parents,  resulting  perhaps  in  only  a  slight  change  in  form  or  structure,  and 
yet  sufficient  to  make  life  easier  and  more  vigorous,  and  capable  of  greater  protec- 
tion, and  possibly  more  attractive  to  mates,  with  increased  chances  of  reproduction. 
Thus  from  generation  to  generation  other  adaptive  variations  are  added — and  in- 
herited by  the  offspring  —  the  higher  adaptive  qualities  crowding  out  the  weaker. 

The  neck  of  the  giraffe  and  the  necks  of  its  million  progenitors,  back  to  the 
first  variation  which  marked  the  beginning  of  this  type,  did  not  grow  to  its  present 
length  by  increasing  the  inherited  lengths  of  its  seven  cervical  vertebrae  during  the 
lives  of  each  of  the  successive  individuals,  even  though  strongly  stimulated  by  the 
demands  of  hunger  and  repeated  eft'orts  to  reach  higher  for  its  tropical  foods. 
Every  marked  change  in  the  slow  development  of  these  adaptive  qualities  arose 
first  with  some  natural  variation  in  the  oft'spring,  which  added  a  little  to  the  length 
of  the  vertebrae  of  the  neck,  giving  them  a  better  chance;  and  in  the  next,  or  some 
succeeding  generation,  another  slight  adaptive  variation  arose  rendering  them  still 
more  fitted  for  the  environment,  and  so  on,  through  myriads  of  variations  to  the 
present  form.  During  these  long  periods,  tho.se  who  were  less  fitted  were  dropped 
from  this  progressively  developing  species  by  dying  out,  or  by  becoming  a  factor 
in  the  development  of  some  other  kind  of  animal,  through  being  forced  into  a  dif- 
ferent environment  for  food,  protection,  etc. 

The  science  of  organic  evolution  which  is  now  accepted  by  all  competent 
biologists  asserts  that  variations  in  plant  and  animal  types,  through  all  the  past 
and  present  forms  of  life,  have  not  originated  because  of  the  stimulation  of  use 
or  influences  of  environment,  but  they  have  arisen  solely  because,  first,  of  the 
law  of  "natural  variation,"  and  second,  the  law  of  heredity,  through  the  admixture 
of  dissimilar  types.  Not  the  smallest  portion  of  an  extra  cusp  of  a  human  tooth 
ever  started  to  develop  because  of  use  or  needs  that  was  not  first  laid  down  in  the 
germ  cells  of  that  individual  through  the  laws  of  heredity  or  "  natural  variation." 
The  infiuences  of  use  and  environment  are  subsequent  forces  upon  already  endowed 
forms  and  qualities,  adapting  the  fitter  types  of  fife  to  the  needs  of  surroundings, 
and  stimulating  them  to  more  vigorous  growth  and  reproductive  activities. 

What  these  unseen  guiding  forces  are — or  any  of  the  objective  qualities  of  all 
natural  forces — we  probably  will  never  know  in  this  life,  or  anything  beyond  the 


42  PARI'   II.     ETIOLOGY   OF   MAWCCLLSfOX 

subjective  cognition  of  the  phenomena  produced.  No  one  can  intelHgently  contem- 
plate the  probable  forces  which  have  been  at  work  during  the  millions  of  past  years 
in  the  origin  and  development  of  organic  life  from  its  simplest  form  up  to  man, 
without  a  profound  feeling  of  awe  for  the  unknowable  guiding  forces  which  set  in 
motion  and  control  this  orderly  sequence  of  events. 

The  men  who  have  been  devoting  their  lives  to  the  possibilities  of  these  laws 
in  the  biologic  field,  in  patient  and  painstaking  investigation,  tell  us  that  these 
are  the  only  ways  in  which  structural  variations  in  organic  life  are  brought  about. 
This  is  not  to  underrate  the  important  part  which  environment  plays  in  the  great 
work  of  evolution.  Nature  selects  only  those  whose  endowments  permit  them  to 
live,  and  those  who  possess  the  more  adaptive  qualities  are  to  that  extent  more 
capable  of  co-ordination,  development,  and  propagation.  They  are,  moreover, 
better  fitted  through  their  vigor  to  aid  in  the  transmission  of  those  adaptive  natural 
variations  which  they  may  have  been  the  very  first  to  possess. 

It  can  be  seen  by  this  that  there  are  three  great  laws  which  have  produced 
and  governed  organic  evolution,  i.  e.,  Heredity,  Natural  Variation,  and  Natural 
Selection.  Influences  of  Environment  upon  individuals  through  immediate  adapt- 
ability to  surrounding  conditions  are  of  far  less  importance,  as  has  been  explained; 
and  yet  a  co-ordination  of  Environment  with  Natural  Selection  has  led  to  the  pre- 
servation and  continuation  of  those  which  are  naturally  best  adapted  to  thrive, 
and  the  weeding  out  of  those  which  are  incapable  of  adaptation  to  the  environment. 

Thus  it  has  been  with  everything,  everywhere  throughout  the  past  ages  in  the 
developmental  processes  toward  surrounding  us  with  untold  variety  of  living  things. 
When  one  begins  to  comprehend  the  wonderful  co-ordination  and  interdependence 
of  the  forces  of  heredity,  variation,  natural  selection,  and  environment,  a  far  far 
deeper  veneration  and  love  arises  for  the  great  Prime  Mover  of  all  things. 

Man  steps  in  and  discovers  these  laws  and  their  action,  and  then  with  his 
artificial  selective  breeding  facilities,  he  hastens  the  operation — that  is  all.  He  does 
not  alter  or  add  to  it  one  single  biologic  law  that  nature  has  not  employed  through 
ceons  of  time.  While  this  is  wholly  true  in  the  science  of  biologic  evolution,  the 
wonderful  work  which  man  has  accomplished  in  the  last  fifty  years,  and  partic- 
ularly in  the  past  few  years,  in  creative  chemical  transformation  of  the  organic  com- 
pounds, which  were  supposed  not  long  since  to  arise  only  from  vital  living  forces,  is 
something  which  now  far  outstrips  the  works  of  nature — freely  demonstrated  in  the 
chemical  transformation  of  the  coal  tar  products  and  their  creative  combination 
with  other  compounds,  as  in  the  making  of  the  aniline  dyes,  etc. 


CHAPTER   VII 
HEREDITY   AND   \'ARIATION    ETHNOLOC7ICALLY   CONSIDERED 

If  the  parents  come  through  long  lines  of  normal  symmetrical  forms  of  propor- 
tionate size  in  relation  to  each  other,  the  offspring  will  follow  the  normal  type — 
barring  natm-al  variation  and  atavistic  heredity  from  distant  inharmonious  pro- 
genitors. If  one  of  the  parents  is  characterized  by  some  definite  disharmony  of 
features,  as  a  marked  disproportion  in  the  size  of  the  nose,  the  ears,  the  jaws,  the 
teeth,  etc.,  there  may  arise  in  the  offspring  any  one  of  a  number  of  definite  forms  of 
products,  or  their  blending  gradations;  the  dominant  and  recessive  types  being 
largely  dependent  upon  the  strength  or  persistence  of  parental  strains. 

It  is  not  a  rare  occurrence,  as  stated  in  the  previous  chapter,  to  find  in  one  such 
family  a  child  having  features  which  show  a  blending  diminution  of  disharmonizing 
characteristics;  another  will  show  a  predominance  of  the  type  of  one  parent  or 
the  other ;  and  in  another  will  be  seen  the  disharmonizing  features  of  one  parent  in 
immediate  association  with  features  which  arc  distinctly  that  of  the  other,  etc. 
Thus,  every  variety  of  change  and  interchange  of  inheritable  features  and  charac- 
teristics— or  those  which  have  not  arisen  in  the  individual  from  extrinsic  causes 
or  environment — possessed  by  parents,  may  arise  in  the  offspring  from  direct 
inheritance. 

Again,  a  child  of  fairly  symmetrically  formed  parents  will  have  some  one  part 
of  the  face  quite  out  of  proportion  in  size,  form,  or  relative  position  to  the  otherwise 
harmonious  features,  but  one  which  has  been  a  characteristic  feature  of  a  grand  or 
great-grand-parent,  or  known  to  have  had  existence  in  some  more  distant  progen- 
itor. Moreover,  the  laws  of  heredity  present  a  variety  of  possibilities  which  can 
neither  be  regarded  as  direct,  nor  as  atavistic  heredity  per  se. 

Mothers  who  have  brought  their  children  to  orthodontists  have  frequently 
said:  "I  don't  see  where  the  child  got  those  prominent  protruding  teeth,  neither  his 
father  nor  I  have  teeth  like  that,  and  so  far  as  we  can  learn  no  member  of  either 
of  our  families  for  generations  back  ever  had  such  teeth."  This  does  not  refer  to 
the  many  similar  expressions  from  the  hps  of  loving  mothers  upon  the  erviption  of 
the  first  permanent  incisors,  which  are  always  far  out  of  proportionate  size  with  the 
"baby"  teeth  and  childhood  features,  and  thus  erroneously  regarded  as  abnormal; 
but  as  the  case  in  question  may  be  one  of  the  dento-facial  protrusions,  let  us  suppose 
by  way  of  examining  biologic  possibilities  from  a  scientific  standpoint,  that  it  is 
one  of  those  extreme  cases  of  bimaxillary  protrusion  in  which  the  entire  dentures  of 
both  ja;ws  are  protruded  in  relation  to  the  mandible  and  other  bones  of  the  skull; 
this  deformity  being  always  enhanced  by  a  "receding  chin  effect."    See  Figs.  157 

43 


44  I'ART   II.     ETIOLOGY   Of   MALOCCLUSION 

and  158,  Chapter  XXIX.  We  will  take  it  for  granted  it  is  true,  that  no  one  in 
either  of  the  two  immediate  famiHes  referred  to  above,  ever  had  a  similar  condition 
of  the  teeth,  and  that  the  said  patient  is  a  child  of  legitimate  birth.  If  this  condition 
of  pronounced  l)imaxillary  protrusion  were  one  of  very  great  rarity,  seen  ])erhaps 
only  once  in  a  lifetime,  it  would  be  called  a  "freak"  by  many.  Others  who  are  firm 
in  their  belief  of  atavism,  even  through  many  generations  of  progenitors,  would  see 
in  it  a  recurrence  of  some  former  type.  But  as  this  particular  form  of  malocclusion, 
in  different  degrees  of  its  prominence,  happens  to  be  one  of  somewhat  common 
occurrence,  seen  plentifully  in  large  cities  of  nations  composed  of  mixed  races, 
there  is  every  reason  to  believe  that  this  and  other  irregularities  of  the  teeth  and 
jaws  have  at  times  arisen  through  the  activities  of  "Mendel's  Law"  in  biologic 
generation,  ivhich  precludes  the  usual  hereditary  necessity  that  so}iie  one  of  the 
forebears  must  have  been  characterized  by  a  similar  goieral  disharjiiony  of  the  features. 
Modern  biologic  investigations  in  crossbreeding  have  abundantly  proven  that  com- 
binations of  the  most  complex  nature  may  be  brought  about  through  the  activities 
of  this  law,  with  results  which  are  at  times  highly  beneficial  in  the  offspring,  and 
again  with  results  which  are  exceedingly  abnormal  in  appearance,  and  so  deficient 
in  adaptive  variations,  that — under  the  law  of  natiu^al  selection — they  soon  become 

extinct. 

Mendel's  Law 

In  the  short  space  of  this  chapter  it  will  be  impossible  to  give  more  than  a 
glance  at  recent  investigations  along  this  line.  The  student  is  referred  to  any 
one  of  the  modern  works  upon  biology  for  a  fuller  description.  The  following  excerpt 
from  a  somewhat  recently  published  textbook  entitled  "Biology,"  by  Stackpole, 
teacher  of  biology  in  Columbia  University,  will  give  a  brief  summary  of  this  phase 
of  heredity:  "Much  attention  has  in  recent  years  been  given  to  the  experimental 
study  of  variation  and  heredity.  These  experiments  are  of  interest  in  connection 
with  Mendel's  Law,  a  law  so  iinportant  in  the  science  of  biology  that  Professor 
Bateson  has  written  of  it,  'The  experiments  which  led  to  this  advance  in  knowl- 
edge are  worthy  to  rank  with  those  that  laid  the  foundation  of  the  atomic  laws  of 
chemistry.'  The  discoverer  of  this  law  was  Gregor  Johann  Mendel  ( 1822-1884) ,  an 
Augustinian  monk.  .  .  .  To  gain  an  idea  of  the  scope  of  these  principles, 
one  cannot  do  better  than  turn  to  Mendel's  own  account  of  his  experiments. 
Punnett's  'Mendelism'  and  Thomson's  'Heredity'  give  such  an  account: 

"  'The  new  science  of  heredity  has  much  to  teach  the  practical  man'  says  Pun- 
nett.  'Let  us  suppose  that  he  has  two  varieties,  each  possessing  a  desirable  charac- 
ter, and  that  he  wishes  to  combine  these  characters  in  a  third  form.  He  must 
not  be  disappointed  if  he  makes  his  cross  and  finds  that  none  of  the  hybrids  approach 
the  ideal  which  he  has  set  before  himself,  for  if  he  raises  a  further  generation  he 
will  obtain  the  thing  which  he  desires.  He  may,  for  example,  possess  tall  green- 
seeded  and  dwarf  yellow-seeded  peas,  and  may  wish  to  raise  a  strain  of  green  dwarfs. 
He  makes  his  cross — and  nothing  but  tall  yellows  result.    At  first  sight,  he  would 


CHAPTER   VII.    HEREDITY  AND   VARIATION  ETHNOLOGIC  ALLY   CONSIDERED     45 

appear  to  be  further  than  ever  from  his  end,  for  the  hybrids  differ  more  from  the 
plant  at  which  he  is  aiming  than  did  either  of  the  original  parents.  Nevertheless, 
if  he  sow  the  seeds  of  these  hybrids,  he  may  look  forward  with  confidence  to  the 
appearance  of  the  dwarf  green  [in  proportion  of  1  to  3  of  the  dominant  tall  yel- 
lows]. And  owing  to  the  recessive  nature  of  both  greenness  and  dwarf ness,  he  can 
be  certain  that  for  further  generations  the  dwarf  greens  thus  produced  will  come 
true  to  type.'  " 

Experiments  with  mice  and  many  of  the  lower  animals  have  so  repeatedly  con- 
firmed these  results  in  all  instances  where  the  conditions  and  requirements  are  ful- 
filled, that  the  principle  is  now  recognized  as  one  of  the  established  laws  of  heredity. 
One  who  is  skilled  in  crossbreeding  can  produce  in  the  oft'spring  any  combination  of 
characters  or  strains  which  are  well  established  by  heredity  in  the  parent  stock. 
Not  only  that,  but  he  can  cause  to  be  completely  dropped  from  the  combination  in 
the  offspring  and  subsequent  generations  of  the  type,  strongly  marked  characters 
of  the  parent  stock.    For  examples,  look  at  the  work  that  Burbank  is  doing  today. 

Now  let  us  apply  this  law  to  our  patient  whose  protruding  teeth  seem  to  have 
arisen  from  no  cause.  Both  parents  may  have  passed  down  from  long  lines  of 
typically  formed  progenitors,  both  families  of  which  were  fairly  symmetrical  in 
physical  forms,  according  to  racial  type,  and  yet  when  the  two  lines  are  compared  to 
each  other,  they  are  genetically  quite  disproportionate  in  size,  physique,  and  charac- 
ter of  features;  the  one  characterized  by  large  strong  bones,  muscles,  and  sinews,  as 
occtirs  with  dominant  types  in  certain  tribal  races,  while  the  other  family  is  built 
on  a  more  delicate  effeminate  plan,  and  yet  with  this  strain  of  its  characteristic 
type  none  the  less  persistent. 

When  one  considers  the  endless  variety  of  unions  which  arise  in  mixed  races, 
it  must  be  realized  that  it  is  no  far-fetched  proposition  that  marriages  have  and  do 
take  place  between  dissimilar  types  who  possess  all  the  exacting  requirements  which 
place  them  under  the  rule  of  Mendel's  Law,  and  with  the  strong  probability  that  the 
first  offspring  of  these  unions  are  characterized  by  the  dominant  type — as  in  the 
production  of  the  "tall  yellow"  peas.  Let  us  suppose  that  this  pertains  to  the  large 
heavy  bones  and  teeth  of  the  stronger  parent.  If  this  character  of  oft'spring  should 
meet  and  marry  other  similar  oft'spring  that  have  arisen  in  the  same  way  (which  is 
more  than  possible),  in  the  second  generation  there  will  be  a  strong  hereditary 
tendency  for  a  recessive  type  to  arise,  or  parts  of  the  recessive  in  combination  with 
the  dominant.  This  means  that  undiluted  physical  characters,  parts  or  properties 
of  the  delicately  constructed  grand-parents  upon  one  side,  will  arise  in  combination 
with  the  strongly  marked  physical  characteristics  of  the  other  grand-parents,  both 
of  whom  composed  the  original  characters  of  these  distinctively  dissimilar  types. 
It  is  not  more  than  possible  that  this  typal  mixture  may  express  itself  through  the 
laws  of  heredity  by  a  disproportionately  large  mandible  or  maxilla  or  both  as  com- 
pared to  the  other  bones  of  the  skull  of  the  individual,  or  may  it  not  be  the  large 
strong  teeth  of  the  dominant  type  in  combination  with  the  smaller  and  more  delicate 


46  PART   II.     ETIOLOGY   OF   MALOCCLUSION 

jaws  of  the  other  as  in  cases  which  Dr.  Cryer  has  mentioned?  The  large  teeth 
striving  to  force  themselves  into  the  small  jaws  are  with  their  alveolar  processes 
natnrally  carried  forward  rather  than  backward,  because  of  the  obstructing  rami 
and  tuberosities,  with  the  production  of  any  one  of  the  decided  dento-facial  pro- 
trusions; and  through  the  same  biologic  processes  that  have  produced  other  im- 
perfections in  facial  outlines  by  an  association  of  immediate  parts  of  physiognomies 
that  are  inharmonious  in  size  or  relation. 

Through  careful  artificial  selection  in  the  processes  of  hybridizing,  excessive 
protruding  mandibles  and  teeth  of  bulldogs  have  been  produced,  together  with 
equally  marked  physical  variations  in  domesticated  animals,  fruits,  flowers,  etc., 
and,  too,  through  methods  of  crossbreeding  not  unlike  those  which  possibly  may, 
and  very  probably  do  oljtain  in  the  multitudinous  variety  of  natural  unions  of 
dissiniilar  types  in  the  human  race,  which  so  often  result  in  disharmonious  combi- 
nations in  the  facial  outlines  of  individuals. 

The  short  upper  jaws  and  prognathic  mandibles  of  pug  and  bull  dogs  arose 
originally  either  from  a  natural  variation  or  from  cross  fertilization.  This  has 
been  increased  to  the  present  types  largely  by  selective  breeding  or  hybridization. 
For  bench  show  purposes  this  biologically  developed  abnormality  is  still  further 
enhanced  artificially  in  the  individual  by  mechanical  devices  which  inhibit  the 
growth  development  of  the  maxilla,  and  through  the  same  channels  of  forces  that 
obstructive  diseases  produce  pathologic  inhibitions.  Physical  changes  in  the  indi- 
vidual, wrought  in  this  way  from  intra-uterine,  post-natal,  or  any  of  the  extrinsic 
local  causes,  however,  are  never  transmitted  to  offspring,  it  being  one  of  the  accepted 
laws  of  biology  that  all  inheritable  characteristics  invariably  receive  their  propa- 
gating qualities  during  the  metabolism  of  the  germ  cells. 

It  has  been  erroneously  asserted  that  "nature  does  not  place  in  one  organ  two 
or  more  parts  that  are  disharmonious  in  their  sizes,"  also  that  "it  is  impossible  for 
two  component  parts  of  any  section  derived  from  the  same  embryonic  bud  of  de- 
velopment to  be  in  disharmony  with  the  whole."  This  is  abvmdantly  disproven  by 
the  many  disharnionies  in  closely  related  parts  repeatedly  exemplified  everywhere 
by  heredity  alone.  Moreover,  it  is  one  of  the  most  constant  and  expected  products 
of  hybridizing.  Were  it  not  for  this,  we  would  not  today  be  enjoying  the  great 
variety  of  fruits  and  flowers  of  our  times. 

In  regard  to  this  phase  of  the  subject,  it  may  be  pardonable  to  quote  the  words 
of  a  prominent  biologist  to  whom  this  principle  of  teaching  was  submitted  for 
criticism:  "A  statement  like — 'nature  never  pvits  teeth  into  a  mouth  that  do  not 
belong  to  that  physiognomy,'  always  arouses  my  ire.  Variation  is  so  thoroughly 
the  rule  in  nature,  not  only  in  individuals,  but  in  parts  of  individuals,  that  there  is 
jiist  as  apt  to  he  disharmony  as  harmony." 

In  this  connection  it  may  be  interesting  to  note  certain  evidences  for  the 
theory  of  far  reaching  atavistic  heredity,  by  comparing  the  physiognomies  and 
jaws  of  the  present  quite  common  bimaxillary  protrusion  of  the  dentures,  shown  in 


CHAPTER    VII.     HEREDITY   AND    VARIATION   ETHNOLOGIC  ALLY   CONSIDERED    47 

Figs.  157  and  158,  Chapter  XXIX,  with  the  physiognomies  and  jaws  of  early 
prehistoric  peoples,  shown  in  Figs.  2  and  3,  which  are  from  a  recently  published 
work  entitled  "Men  of  the  Old  Stone  Age  :  Their  Environment,  Life,  and  Art," 
by  Henry  Fairfield  Osbom,  of  the  American  Museum  of  Natural  Histor}^  and 
Professor  of  Anthropology  in  Columbia  University,  published  by  Charles  Scribner's 
Sons.    By  permission  of  the  Publishers. 

Fig.  2. 


Three  views  of  the  Piltdown  skull  as  reconstructed  by  J.  H.  McGregor, 
1915.  This  restoration  includes  the  nasal  bones  and  canine  tooth, 
which  were  not  known  at  the  time  of  Smith  Woodward's  reconstruc- 
tion of  1913.  One-quarter  life  size.  Copyright,  1915, 191S.  by  Charles 
Scribner's  Sons. 

The  receding  chin  was  such  a  predominating  characteristic  of  the  early  races 
of  the  old  stone  age  that  they  are  frequently  spoken  of  as  the  "chinless  men." 
In  other  words,  their  stage  of  evolution  still  had  left  stamped  upon  them  certain 
characteristics  of  the  teeth  and  jaws  which  doubtless  had  arisen  in  their  anthropoid 
progenitors  from  prehensile  needs.  This  consisted  in  protruding  dentures  in  rela- 
tion to  the  maxillae  in  which  they  were  placed,  a  condition  of  all  ape  tribes  and 
common  to  Negroid  races.  And  though  this  type  prevailed  ages  before  the  chin 
development  of  the  mandible,  which  later  characterized  the  men  of  the  upper 
palaeolithic  age  and  the  present  "homo  sapiens,"  it  will  nevertheless  be  seen  that 


48 


/MA'/    //.    jynoLOGV  Of  mawcclusiox 


the  facial  uiitlincs  of  these  early  races  were  not  far  unlike  those  of  many  physiog- 
nomies of  today,  which  are,  from  some  form  of  heredity,  characterized  by  the  same 
liimaxillary  protrusion  of  the  dentures,  or  with  the  same  receding  chin  effect  as 
the  el  unless  men. 

In  the  illustration  of  a  paper  read  before  the  1913  meeting  of  the  National 
Dental  Society,  the  author  presented  fifteen  cases  of  bimaxillary  protrusion.  In 
nearly  all  the  cases  shown,  the  buccal  teeth  were  as  perfect  in  alignment  and  occlu- 

FiG.  3. 


V 


The  Piltdown  man  of  Sussex.  England.  Antiquity  variously  esti- 
mated at  100,000  to  300,000  years.  The  ape-like  structure  of  the 
jaw  does  not  prevent  the  expression  of  a  considerable  degree  of 
intelligence  in  the  face.  After  the  reconstruction  modelled  bv 
J.  H.  McGregor.  Copyright.  1915,  19IS.  by  Charles  Scribner's 
Sons. 

sion  as  we  commonly  find  in  normal  dentures.  With  the  exception  of  one  of  these 
cases,  so  far  as  can  be  learned,  no  condition  which  resembled  this  character  existed 
with  the  parents  or  any  of  the  known  forebears;  and  this  was  true  also  of  Dr.  Cryer's 
case.    See  Fig.  24,  Chapter  X. 

One  thing  which  very  strongly  illustrates  the  persistent  forces  of  heredity  in 
physical  structures  and  their  relations,  which  have  arrived  at  a  condition  of  equili- 
bration or  state  of  high  perfection  in  relation  to  environment,  is  obtained  by  a 
careful  study  of  the  photographic  pictures  of  the  jaws  and  dentures  of  prehistoric 
man,  and  the  scientific  restorations  found  in  many  of  the  illustrations  of  Professor 
Osborn's  book,  one  of  which  is  shown  in  Fig.  2.     It  proves  that  the  inherited 


CHAPTER    VII.     HEREDITY   A.\D    VARIATION   ETHNOLOGIC  ALLY   CONSIDERED    49 

standard  type  of  normal  occlusion  of  the  hviman  dentures — contrary  to  the  opinion 
of  many  teachers  of  modern  orthodontia — has  come  down  to  us  essentially  un- 
changed through  the  ages  from  the  prehistoric  men  of  the  "old  stone  age,"  and  kept 
in  line  through  "the  law  of  natural  selection"  ("survival  of  the  fittest"),  and  its 
perfect  adaptation  to  needs. 

Even  as  far  back  as  the  second  "interglacial  period" — 200,000  to  350,000 
years  ago — the  forms,  number,  and  relative  position  of  the  teeth  and  their  buccal 
occlusion  was  essentially  the  same  as  the  standard  normal  ( )cchision  of  today.  And 
though  in  earlier  stages  of  that  vast  period,  the  jaws  were  of  a  heavier  type  and  the 
bimaxillary  protrusive  mouths,  enhanced  by  chinless  m.andibles,  showed  their 
distant  descent  from  their  anthropoid  progenitors,  the  occlusion  of  the  teeth,  their 
alignment  and  arch  form — even  the  canines  which  had  thrown  off  nearly  all  their 
carniverous  characteristics — were  (ill  practically  the  same  as  today.  In  this  connec- 
tion compare  the  protrvided  malposition  of  the  dentures  in  relation  to  the  maxillae  and 
mandibles,  shown  in  Fig.  2,  illustrative  of  the  men  who  lived  hundreds  of  thousands 
of  years  ago,  with  illustrations  of  more  recent  skulls;  first,  the  Fan  Tribe  West 
African  Negro,  Figs.  21  and  22,  and  second.  Dr.  Cryer's  patient.  Fig.  24,  all  in 
Chapter  X.  He  assures  the  author  that  in  the  latter  case  the  buccal  teeth  were 
in  normal  occlusion. 

There  is  no  doubt  in  the  minds  of  advanced  anthropologists  that  the  form, 
structure,  and  relation  of  the  bones  of  the  human  skull  like  those  of  other  bones  of 
tlie  body  were  evolved  from  beings  very  much  lower  in  the  animal  scale,  through  the 
unwavering  laws  of  heredity,  variation,  natural  selection,  and  influences  of  en- 
vironment. And  that  peoples  from  the  very  earliest  age  of  man  up  to  the  present 
time,  through  segregations  in  distantly  located  parts  of  the  globe,  presenting  marked 
differences  of  environment,  have  become  through  slight  ethnologic  variations 
during  many  ages,  the  different  races,  characterized  by  distinct  types  in  color  and 
character  of  skin  and  hair,  and  of  physical  framework  of  physiognomies. 

While  there  are  at  present  only  three  markedly  distinct  races — the  white 
or  Caucasian,  the  yellow  or  Mongoloid,  and  the  black  or  Negroid — through  ad- 
mixtures by  intertribal  relations  and  more  distant  migrations,  many  quite  distinct 
races  have  been  formed,  with  the  production  of  intervening  types,  of  which  it  is 
said,  if  they  could  be  collected  and  compared,  would  blend  into  each  other  with 
imperceptible  gradations. 

This  is  a  subject  which  pertains  to  the  established  sciences  of  stomatology  and 
ethnology — branches  of  anthropology — which  are  today  taught  in  our  colleges, 
and  which  are  founded  upon  many  years  of  patient  careful  investigations  by  the 
most  learned  scientific  minds. 

It  is  shown  that  the  present  white  race,  more  than  any  of  the  others,  is  decidedly 
a  mixed  race,  there  being  few  if  any  left  of  the  original  representatives  of  the 
Caucasian  type,  to  which  we  are  accustomed  to  refer  as  the  standard  of  beauty 
and  physical  perfection.    Yet  because  of  the  fact  that  our  taste  and  appreciation 


50  PART   II.     ETIOLOGY  OF   MALOCCLUSION 

of  these  qualities  are  being  varied  under  the  same  adaptive  guiding  forces  of  evolu- 
tion which  have  characterized  the  physical,  we  not  uncommonly  meet  with  types 
which  fully  accord  with  our  own  understanding  of  manly  and  womanly  beauty  and 
perfection.  This  doubtless  has  been  true  also  of  all  isolated  races  of  peoples,  the 
more  primitive  of  which  we  would  now  regard  as  exceedingly  unattractive  and 
perhaps  repulsive. 

In  this  brief  mention  of  a  few  of  the  well  established  principles  iind  possibili- 
ties of  the  laws  of  heredity  and  their  co-operating  forces  with  reference  to  the 
influences  they  exert  in  producing  dental  and  dento-facial  malformations,  the 
author  has  endeavored  to  place  before  the  mind  of  the  reader  a  broader  appre- 
ciation of  the  subject  than  that  which  is  popularly  tinderstood  as  heredity,  with 
the  hope  that  it  will  lead  to  a  more  comprehensive  study  of  these  great  principles 
which  have  such  an  intimate  bearing  upon  many  conditions  which  come  within 
the  scope  of  dental  orthopedic  practice. 


CHAPTER  Mil 

PRACTICAL   APPLICATION   OF   BIOLOGIC   LAWS 

What  interests  us  most  as  orthodontists,  especially  as  we  essay  the  correction 
or  improvement  of  facial  beauty  that  is  marred  or  deformed  by  malpositions 
and  malrelations  of  the  teeth  and  jaws,  is  the  fact  that  in  our  country — the  United 
States  above  all  other  countries — the  union  of  dissimilar  types  occurs  most  fre- 
quently. The  laws  of  heredity  do  not  necessarily  produce  in  the  offspring  a  blended 
composite  type.  In  fact,  such  an  occurrence  from  parents  of  dissimilar  types 
of  both  plants  and  animals  often  exhibits  an  association  of  separate  distinct  physi- 
cal characters  that  have  come  from  both  parents  or  their  progenitors.  A  slight 
observation  of  family  physiognomies  must  fully  demonstrate  the  inheritance  of 
distinct  features  of  both  parents,  and  when  this  occurs  in  the  associated  parts  of  a 
physiognomy,  it  may  result  in  decided  disharmony  of  the  features.  "For  nature 
knows  no  laws  of  esthetics,  as  beautiful  and  harmonious  as  her  products  are." 

Under  the  forces  of  atavistic  heredity,  also,  there  have  frequently  arisen  peculiar 
and  inharmonious  characteristics  which  could  not  be  remembered  as  having 
previous  existence  in  immediate  forebears,  but  which  have  been  definitely  traced 
through  records  of  history  to  some  very  distant  progenitor. 

These  laws  were  fully  recognized  by  both  Darwin  and  Wallace  in  the  earlier 
researches  of  evolution.  Huxley,  more  than  forty  years  ago,  in  writing  upon  the 
laws  of  heredity  and  variation,  said:  "It  is  a  matter  of  perfectly  common  ex- 
perience that  the  tendency  on  the  part  of  the  offspring  always  is  to  reproduce  the 
form  of  the  parents;  that  is  a  matter  of  ordinary  and  familiar  observation.  In  all 
cases  of  propagation  and  perpetuation,  there  seems  to  be  a  tendency  in  the  oft'spring 
to  take  the  characters  of  the  parental  organisms.  You  do  not  find  that  the  male 
follows  the  precise  type  of  the  male  parent,  nor  does  the  female  always  inherit  the 
precise  characteristics  of  the  mother — -there  is  always  a  proportion  of  the  female 
characters  in  the  male  oft'spring,  and  of  the  male  characters  in  the  female  offspring. 
There  are  all  sorts  of  intermixtures,  and  intermediate  conditions  between  the  two  of 
dissimilar  types,  when  complexion,  beauty,  or  fifty  other  different  peculiarities 
belonging  to  either  side  of  the  house  are  reproduced  in  other  members  of  the  same 
family.  You  will  also  see  a  child  in  a  family  who  is  not  Uke  either  its  father  or 
mother;  but  some  old  person  who  knew  its  grandparents,  or  it  may  be  an  uncle,  or 
perhaps  a  more  distant  relative,  will  see  a  great  similarity  between  the  child  and 
one  of  these." 

The  disharmonies  in  esthetic  facial  outlines  which  are  caused  from  malposed 
teeth  are  quite  as  diversified  as  disharmonies  in  size,  form,  and  relation  of  the 

51 


52  PART  IT.     FTror.OGV   OF   MALOCCLUSION 

features  of  different  physiognomies  compared  to  the  symmetricaL  How  often  do 
we  see  some  one  feature  of  a  face  too  large  or  too  small  for  the  rest  of  the  features 
of  which  it  forms  a  part,  and  this  is  true  in  varying  degrees  of  every  feature  and 
organ  of  the  human  l)ody  as  compared  to  that  which  may  be  considered  as  the  truly 
normal  or  symmetrically  formed  type. 

The  surface-contour,  form,  size,  and  varying  positions  of  the  features  which 
compose  the  human  physiognomy  are  largely  dependent  upon  the  osseous  frame- 
work, which  in  turn  is,  normally,  either  an  inherent  type  or  the  union  in  the  off- 
spring of  types  which  vary  from  harmony  to  the  distinctively  disharmonious.  In 
all  conditions  of  health  and  normality,  these  same  influences  and  laws  of  develop- 
ment constitvite  the  causes  which  govern  and  determine  the  relative  sizes  and  forms 
of  every  organ  and  natural  contour.  From  these  sources  have  mainly  arisen  all  the 
distinctively  different  types  of  races. 

In  America,  where  the  union  of  disharmonious  types  has  had  full  sway,  we  find  a 
great  variety  of  disharmonies  in  the  physical  forms  of  its  inhabitants.  On  the  other 
hand,  among  peoples  such  as  the  Japanese  and  the  Chinese,  whose  native  countries 
are  not  so  extensively  encroached  ttpon  with  the  intermingling  of  foreign  types,  indi- 
vidual disharmonies  and  variations  from  the  racial  type  are  comparatively  uncom- 
mon. And  while  their  characteristic  type,  from  our  viewpoint,  may  be  far  from  that 
which  we  recognize  as  the  highest  physical  development  in  beauty  and  perfection  of 
form,  it  nevertheless  is  that  which  has  normally  arisen  under  the  influence  of  heredity, 
natural  selection,  and  environment,  and  consequently  to  them  it  is  a  normal  type. 

One  of  the  characteristic  dento-facial  types  that  is  common  with  a  Japanese 
physiognomy  is  a  depression  or  unesthetic  retrusion  along  the  upper  part  of  the 
upper  lip,  and  at  the  base  of  the  rarely  prominent  nose.  This  depression  heightens 
the  usual  pronounced  malar  prominences  and  shortens  the  somewhat  thin  upper 
lip  in  its  relation  to  the  incisal  ends  of  the  teeth — the  lip  itself  approaching  a  pre- 
hensile inclination  of  45  degrees.  In  a  number  of  cases  which  the  author  has  exam- 
ined, the  disto-mesial  relations  of  the  buccal  teeth  were  normal  in  occlusion,  while 
the  labial  teeth,  particularly  the  incisors,  were  more  labially  inclined  than  we 
would  consider  esthetically  normal.  The  cutting  edges,  especially  of  the  upper 
incisors,  were  more  or  less  protruding,  which  seemed  to  be  due  to  a  retrusion  of  the 
apical  zone,  or  that  which  we  would  denominate  from  an  esthetic  standpoint,  a 
repression  of  the  normal  development  of  the  middle  features  of  the  physiognomy. 
If  this  condition,  which  is  a  normal  Japanese  type,  occurred  with  an  Anglo-Saxon, 
as  it  occasionally  does,  it  would  be  diagnosed  as  decidedly  abnormal,  notwithstand- 
ing the  perfect  occlusion  of  the  buccal  teeth.  And  in  all  probability,  if  not  an  in- 
herited type,  it  would  be  caused  by  some  abnormal  condition  of  the  maxillary 
sinuses,  and  result  in  a  lack  of  development  of  the  intermaxillary  processes,  and 
would  demand  a  bodily  protrusive  movement  of  the  apical  zone  of  the  incisors,  and 
a  retrusive  movement  of  the  incisal  zone  to  correct  the  facial  outlines.  See  Type 
C,  Division  2,  Class  II. 


CHAPTER   VIII.    PRACTICAL  APPLICATION  OF  BIOLOGIC  LAWS  53 

]\Iuch  could  be  written  and  quoted  along  this  line,  but  space  will  not  permit. 
With  a  moderate  understanding  of  the  ethnologic  principles  of  biologic  develop- 
ment, it  will  be  seen  that  all  forms  of  animal  life  about  us  are  the  offspring  of  pro- 
genitors whose  physical  and  mental  characteristics  they  repeat  to  a  very  large 
extent,  either  by  direct  inheritance  with  the  blending  of  types  or  with  the  associa- 
tion of  the  distinct  characters  of  one  or  both  parents,  or  through  atavism  from  more 
distant  progenitors,  etc. 

The  immediate  association  in  the  physiognomies  of  individuals  of  distinct 
characteristics  of  the  different  racial  types  from  which  they  sprung,  through  some 
form  of  heredity  in  which  Mendel's  Law  may  have  played  a  part,  is  one  of  the  most 
important  ethnologic  considerations.  In  connection  with  these  sources  of  reproduc- 
tion, one  should  not  forget  that  the  law  of  natural  variation  is  always  and  every- 
where in  action  through  the  metabolic  activities  of  the  germ  cells,  with  the  same 
transmissible  properties  as  those  of  long  lines  of  heredity. 

Principles  of  Heredity  in  Relation  to  Treatment 
The  following  phase  of  this  subject  pertains  to  that  which  we  find  exempli- 
fied everywhere  about  us.  First,  to  the  relationship  as  regards  size,  form,  and 
relative  position  of  the  mandibular  and  maxillary  bones  proper,  to  the  rest  of 
the  bones  which  form  the  framework  of  physiognomies;  second,  to  the  relations 
of  the  dental  and  alveolar  arches  to  the  mandibles  and  maxillae — both  with  a 
view  of  comparing  the  disharmonies  we  commonly  find,  to  that  harmony  of 
dento-facial  relation  w^hich  accords  with  our  present  standard  of  perfection  and 
beauty. 

It  will  be  seen  that  the  types  of  people  present  the  most  marked  differences 
in  the  form  and  size  of  the  bones  which  constitute  the  framework  of  human  bodies. 
Thus  we  have  tall  and  short  men,  either  of  whom  may  possess  strong  heavily  built 
bones  or  slender  delicate  ones.  Nor  does  esthetic  harmony  or  the  typically  anatomic 
prevail,  except  rarely.  Moreover,  it  is  common  to  find  disharmonies  in  the  sizes 
and  relations  of  bones  which  are  closely  associated  as  the  bones  of  the  face,  and 
which  can  frequently  be  traced  to  direct  inheritance  or  the  admixture  through  some 
channel  of  heredity  of  disharmonious  types. 

In  this  investigation,  which  anyone  with  an  observing  mind  may  pvu-sue,  there 
will  be  found  to  exist  every  possible  variation  between  the  so-called  "freaks"  and 
those  of  Apollo-like  harmony  and  perfection.  We  find  noses  of  every  possible  shape 
in  relation  to  harmony  with  the  features  upon  which  they  are  placed,  and  jaws  prog- 
nathous and  retruded  in  relation  to  the  rest  of  the  features.  This  must  be  equally 
true  of  the  sizes  of  teeth  whose  width  measurements  have  been  erroneously  em- 
ployed to  determine  the  sizes  of  the  newly  regulated  dental  arches.  If  the  sizes  of 
dental  arches  are  made  in  exact  mathematical  proportion  to  the  width  of  the  upper 
central  incisors,  will  not  these  arches  be  found  at  times  too  large  or  too  small  for 
facial  harmony,  and  to  an  extent  that  is  noticeably  deforming?    We  frequently  find 


54  PART  II.     ETIOLOGY  OF   MALOCCLUSION 

the  sizes  of  the  front  teeth  quite  out  of  proportion  with  the  features.  Moreover, 
the  circumference  measurements  of  the  right  and  left  centrals  and  other  teeth  are 
rarely  exactly  the  same,  and  commonly  vary  in  their  circumferences  under  normal 
conditions,  V64  to  V32  of  an  inch,  and  at  times  even  more. 

Many  of  the  facial  disharmonies  pertain  to  the  dental  and  maxillary  frame- 
work, and  characterize  the  physiognomies  as  plain,  homely,  or  deformed,  according 
to  the  character  and  amount  of  the  protrusion  or  retrusion  over  the  dento-facial 
and  mandibtilar  area. 

In  many  protrusions,  both  unimaxillary  and  bimaxillary,  the  entire  bodies 
of  the  maxillary  bones  are  protruded  in  their  dento-facial  relations,  and  this  is 
easily  determined  by  the  prominence  of  the  chin  and  the  prominence  at  the  base 
of  the  nose  and  along  the  upper  portion  of  the  upper  lip.  In  many  of  these  cases 
the  teeth  are  in  perfect  harmony  of  size  and  position  with  the  protruded  jaws — in 
arch  width,  alignment,  and  inclination — and  yet  distinctly  out  of  balance  with  the 
esthetic  relations  of  the  rest  of  the  features.  In  bimaxillary  malpositions  the  dentures 
are  often  found  in  typical  occlusion  in  the  white  as  well  as  in  colored  races,  because 
both  dentures  are  equally  protruded.  Again,  in  a  large  proportion  of  protrusions, 
the  protrusion  pertains  mostly  or  wholly  to  the  dental  and  alveolar  arches  alone. 
As  an  illustration  of  this,  see  the  beginning  of  Dr.  Cryer's  case.  Chapter  X,  and  the 
physiognomies  of  bimaxillary  protrusions  illustrated  in  this  work.  Moreover, 
in  nearly  all  typical  protrusions  of  the  dentures  not  due  to  local  causes,  the  teeth 
are  crowded  closely  together,  showing  that  the  l^uccal  teeth  partake  of  the  protruded 
malposition  quite  as  much  as  the  labial  teeth. 

Fig.  4. 


Attention  is  called  also  to  the  variety  of  antero-posterior  malpositions  of  the 
lower  denture  in  relation  to  the  mandible.  Fig.  4  is  made  from  the  facial  casts  of 
two  cases  before  treatment.  The  mandible  of  the  one  on  the  right,  judging  from  the 
facial  outlines,  is  seen  to  be  decidedly  prognathous,  but  from  the  relative  position 
of  the  lower  lip,  the  lower  denture  must  be  in  about  normal  dento-facial  relations. 
With  the  case  on  the  left,  judging  from  the  relative  positions  of  the  chin,  the  lower 


CHAPTER    VIII.    PRACTICAL  APPLICATION  OF  BIOLOGIC  LAWS  55 

lip,  and  labio-mental  curve,  these  conditions  are  reversed,  that  is:  the  mandible  is 
in  esthetic  dento-facial  relations,  laut  with  the  lower  denture  protruded. 

These  two  cases  like  many  others  which  could  be  pointed  out  in  this  work, 
illustrate  the  decided  dissimilarity  in  types  which  may  arise  -witJi  the  same  character 
of  occlusion  of  the  dentures.  These  belong  in  Class  III  in  which  the  upper  denture 
is  more  or  less  retruded,  and  with  the  lower  denture  closing  far  in  front  of  a  normal 
occlusion  with  the  upper  denture.  Illustrations  of  this  kind,  moreover,  definitely 
show  that  through  that  most  prolific  form  of  heredity — i.  e.,  the  sexual  union  of 
dissimilar  characters — even  entire  upper  or  lower  dentures  take  decidedly  difterent 
positions  at  times  in  relation  to  the  bones  in  which  they  grow. 

TIius  uHDiy  of  the  )i!ost  pronounced,  as  ivell  as  niitior  malocclusions,  having  every 
possible  malrelation  of  the  teeth,  jaivs,  and  facial  oullijies,  have  arisen  through.  o)ie 
of  the  many  avenues  of  heredity.  The  proof  of  this  statement  is  so  plainly  shown 
on  every  hand,  and,  moreover,  it  accords  so  thoroughly  with  the  laws  of  biology 
in  both  flora  and  fauna,  that  the  fantastic  claims  that  "all  malocclusions  arise  from 
local  causes,"  and  "God  does  not  make  such  mistakes  in  forming  the  human  anat- 
omies, etc.,"  must  be  regarded  as  crass  ignorance  of  the  well  established  principles 
of  heredity. 

This  brings  us  to  a  point  which  should  be  emphasized,  because  it  pertains 
to  the  civiestion  of  early  correction,  and  particularly  to  the  teaching  of  shifting 
the  deciduous  buccal  teeth  and  recently  erupted  first  molars  to  normal,  in  all 
cases  of  disto-mesial  malocclusion,  even  though  the  buccal  cusps  are  in  full 
malinterdigitation. 

It  should  be  understood  that  the  author  is  heartily  in  accord  with  this  move- 
ment for  young  patients,  where  it  is  distinctly  seen  to  be  demanded.  The  cases 
that  demand  it  are:  first,  those  which  arise  from  local  causes  and  which  otherwise 
would  have  been  in  normal  relations;  and  second,  from  whatever  cause,  if  one  den- 
ture or  the  other  is  retruded  in  its  dento-facial  relations,  and  the  other  is  not  so 
protruded  but  that  the  slight  distal  naovement  that  is  necessary  for  its  correction 
can  be  safely  and  advisedly  performed. 

If  it  is  other  than  this,  as  it  is  quite  liable  to  be,  where  the  lower  denture  is 
destined  to  be  normal  or  not  protruded,  and  the  opposing  denture,  through  hered- 
ity, is  destined  to  be  decidedly  protruded,  the  operator  can  rest  assured  that  the 
shifting  of  the  first  molars  to  a  normal  occlusion,  at  whatever  age,  will  ultimately 
result  in  a  bimaxillary  protrusion,  permanently  marring  the  beauty  of  the  face. 
Nor  can  one  be  sure  what  the  adult  conditions  are  destined  to  be  at  this  very  early 
age,  when  the  bones  are  just  beginning  to  take  on  the  inherent  stamp  of  their 
progenitors. 

In  the  hundreds  of  cases  which  have  come  under  the  author's  observation 
during  the  ages  of  childhood  and  youth,  there  is  no  room  to  spare  in  the  jaws  back 
of  the  deciduous  molars,  except  at  the  time  preparatory  to  the  eruption  of  the  first 
permanent  molars,  and  finally  the  second,  and  then  the  third  molars;  the  latter 


56  PART   II.     F.TIOUK.y   OF   MALOCCLUSION 

being  often  obliged  to  occupy  qviite  as  crowded  positions  in  protruding  cases  as 
are  seen  when  teeth  are  not  protruded.  In  other  words,  in  all  cases  of  typical  pro- 
trusion in  the  white  race  due  to  heredity,  the  natural  position  of  the  back  teeth  in 
relation  to  the  tuberosities  and  rami  allows  no  more  than  a  very  moderate  distal 
movement  without  encroaching  upon  space  demanded  for  the  succeeding  molars, 
a  demand  which  nature  will  at  one  time  or  another  insist  upon,  or  else  make  trouble. 

Therefore,  in  all  marked  inherent  protrusions  of  the  upper,  for  example,  if  the 
first  molars  are  extensively  moved  distally  for  the  purpose  of  placing  them  in  a 
normal  occlusion  in  early  childhood  or  later,  one  may  count  ([uite  surely  upon  ulti- 
mate disappointment  of  intention.  If  the  teeth  do  not  go  back  to  their  former 
inherited  malinterdigitation,  as  they  are  quite  liable  to  do  through  the  eruptive 
forces  of  the  second  or  third  molars,  a  bimaxillary  protrusion,  which  is  quite  as  bad, 
will  be  stamped  upon  the  features  through  life. 

In  the  discussion  of  a  paper  read  before  a  prominent  society  upon  the  advantages 
of  radiographs  in  orthodontia,  a  prominent  teacher  in  a  dental  college — who  evi- 
dently had  caught  the  "bone  growing"  fever — criticised  Dr.  Cryer's  warning  in 
regard  to  the  excessive  distal  movement  of  molars,  and  he  did  this  upon  the  bare 
evidence  of  a  single  case  that  he  illustrated  with  the  lantern,  showing  a  third  molar 
which  evidently  had  been  impacted  by  a  distal  artificial  movement  of  a  second 
molar,  and  which  had  finally  erupted  to  normal  position.  This  speaker  expressed 
in  unmistakable  terms  his  belief  that  the  crowding  of  the  teeth  and  the  artificially 
applied  forces  will  stimulate  an  interstitial  extra  growth  and  elongation  of  the  jaw- 
bone itself,  and  thus  carry  all  the  denture  forward  and  give  plenty  of  room  for  the 
third  molars.  This  is  abundantly  proved  to  be  untrue  by  the  many  instances  of 
crowded  dentures  that  are  protruded  in  relation  to  the  jaws  in  which  they  are 
placed. 

If  nature  possessed  this  power  in  the  individvial  to  cause  the  jaws  and  associate 
bones  to  grow  to  meet  the  requirements  of  room  and  facial  harmony,  or  if  it  were 
possible  for  vis  to  stimulate  nature  to  an  extra  interstitial  growth,  there  would  be 
far  more  harmonious  relations  between  the  sizes  of  dentures  and  jaws  than  are 
seen  to  exist.  We  would  not  so  frequently  see  retruded  chins  in  connection  with 
crowded  and  prominent  lower  teeth,  or  those  marked  cases  of  bimaxillary  protru- 
sion which  are  not  usually  noticeable  until  ten  or  twelve  years  of  age,  and  which 
seem  to  increase  in  prominence  during  adolescence. 

There  is  every  reason  to  believe  from  the  most  advanced  authorities  upon 
biology  that  the  bones  of  individuals  cannot  be  forced  to  grow  larger  than  their 
inherited  sizes,  nor  would  they  have  ever  grown  larger  than  any  primitive  fixed 
state,  had  it  not  been  for  the  laws  of  natural  variation  and  "survival  of  the  fittest." 

The  following  quotation  from  Stackpole's  "Biology,"  should  forever  set  at  rest 
the  fantastic  theory  of  "bone  growth."  "//  is  well  known  that  all  auinials  and  plants 
have  a  definite  limit  of  growth.  From  the  cytological  point  of  view,  the  limit  of 
body-size  appears  to  be  correlated  with  the  total  number  of  cells  formed  rather  than 


CHAPTER   VIII.    PRACTICAL  APPLICATION  OF  BIOLOGIC  LAWS  57 

with  their  individual  size.  This  relation  has  been  carefully  studied  by  Conkline 
('96)  in  the  case  of  the  gasteropod  Crepidula,  an  animal  which  varies  greatly  in 
size  in  the  mature  condition,  the  dwarfs  having  in  some  cases  not  more  than  one- 
twenty-fifth  the  volume  of  the  giants.  The  eggs  are,  however,  of  the  same  size  in 
all,  and  their  number  is  proportional  to  the  size  of  the  adult.  The  same  is  true  of  the 
tissue-cells.  Measurements  of  cells  from  the  epidermis,  the  kidney,  the  liver,  the 
alimentary  epithelium,  and  other  tissues,  show^  that  they  are  on  the  whole  as  large 
in  the  dwarfs  as  in  the  giants.  The  body-size  therefore  depends  on  the  total  number 
of  cells  rather  than  on  their  size,  individually  considered,  and  the  same  appears  to 
be  the  case  in  plants." 


PART   III 


Basic  Principles  of  Practice 


BASIC  PRINCIPLES  OF  PRACTICE 


ARRANGEMENT 


CHAPTER   IX 

UI'  THE  TEETH  AND  ALVEOLAR  PROCESS  ANATOAUCALLY 
CONSIDERED 


The  foundation  of  all  training  calculated  to  fit  one  to  enter  the  practical  field  of 
Orthopedic  Dentistry  must  lie  in  a  perfect  knowledge  of  nature's  anatomical  arrange- 
ment and  occlusion  of  the  teeth,  and  the  form  and  structure  of  the  alveolar  process. 

This  is  most  perfectly  described  in  the  incomparable  work  "Dental  Anatomy," 
by  Dr.  G.  V.  Black,  who  has  kindly  permitted  the  re-publication  of  it  in  this  chapter. 


ARRANGEMENT  OF  THE  TEETH 


Fig.  5. 


"The  upper  teeth  are  arranged  in  the  form 
of  a  semi-ellipse,  the  long  axis  passing  be- 
tween the  central  incisors.  In  this  cvirve,  the 
cuspids  stand  a  little  prominent,  giving  a  full- 
ness to  the  comers  of  the  mouth.  In  differ- 
ent persons  there  is  much  variation  in  the 
form  of  the  arch  within  the  limits  of  the 
normal.  Occasionally  the  bicuspids  and  mo- 
lars form  a  straight  line,  instead  of  a  curve, 
and  frequently  the  third  molars  are  a  little 
outside  the  line  of  the  ellipse.  In  the  ex- 
amination of  casts  of  the  most  perfect  den- 
tures, it  is  found  that  the  two  sides  do  not 
perfectly  con-espond,  and  that  certain  teeth 
deviate  slightly  from  the  perfect  line.  The 
incisors  are  arranged  with  their  cutting  edges 
forming  a  continuous  curved  line  from  cuspid 
to  cuspid,  and  this  line  is  continued  over  the 
cusps  of  the  cuspids  and  the  buccal  cusps  of 
the  bicuspids  and  molars  to  the  distal  surface 
of  the  third  molars.  From  the  first  bicvispid 
to  the  third  molar  the  lingual  cusps  of  these 
teeth  form  a  second  line  of  elevations.     Be- 

Gl 


62 


PART   III.     BASIC  PRINCIPLKS  OF   PRACTICE 


tween  these  two,  the  linj^aial  and  buccal  cusps,  there  is  a  conlimuius  but  irregular 
valley,  or  sulcus. 

"The  lower  teeth  are  arranged  similarly  but  on  a  slightly  smaller  curve,  so 
that  the  line  of  the  ellipse,  which  falls  on  the  buccal  cusps  of  the  upper  bicuspids 
and  molars,  will  fall  upon  the  buccal  surfaces  near  the  gum  on  the  lower  teeth 
(Fig.  5).  Therefore  in  occlusion  the  upper  teeth  project  a  little  to  the  labial  and 
buccal  of  the  lower  at  all  points  of  the  arch  (Fig.  ()).     The  incisors  and  cuspids 

Fig.  6. 


occlude  so  that  the  cutting  edges  of  the  lower  incisors  and  cusps  of  the  cuspids 
make  contact  with  the  lingual  surfaces  of  the  similar  teeth  of  the  upper  jaw  near 
their  cutting  edges  (Fig.  7).  In  this,  however,  there  is  much  variety  within  the 
limits  of  a  normal  occlusion.  Sometimes  the  lower  incisors  strike  the  lingual  sur- 
faces of  the  upper  n^ar  the  linguo-gingival  ridge,  and  may  strike  at  any  point 
between  that  and  the  cutting  edges.  In  abnormal  occlusions  the  lower  incisors 
niay  miss  the  upper,  striking  the  gunis  posterior  to  theni,  or  they  may  occlude 
anterior  to  the  upper  incisors.  The  broad  cusped  occluding  surfaces  of  the  bicus- 
pids and  molars  of  the  opposing  dentures  rest  on  each  other  in  such  a  way  that 
the  lingual  cusps  of  the  tipper  teeth  fit  with  more  or  less  accuracy  into  the  gen- 
eral sulcus  formed  between  the  buccal  and  lingual  cusps  of  the  lower  teeth.  The 
buccal  row  of  cusps  of  the  lower  teeth,  in  a  similar  way,  are  fitted  into  the  sulcus 
formed  between  the  buccal  and  lingual  cusps  of  the  upper  teeth  (Figs.  8  and  9). 
This  arrangement  is  such  that  when  the  teeth  are  in  occlusion  it  leaves  the  buccal 


CHAPTER   IX.     ARRAXGEMEXT  OF   THE   TEETH 


63 


Fig. 


Fig.  S. 


/V 


inclines  of  the  buccal  cusps  of  the  upper  teeth  outside  the  buccal  surfaces  of  the 
upper  teeth  (a).  And,  also,  leaves  a  ledge  formed  by  the  abrupt  lingual  inclines 
of  the  lingual  cusps  of  the  lower  teeth  along  the  lingual  line  of  the  occlusion  (b). 
This  brings  the  occluding  surfaces  of  the  teeth  in  the  best  form  of  apposition  for 
the  purposes  of  mastication.     The  forms  presented  to  the  cheek  and  to  the  tongue 

hold  these  soft  tissues  a 
little  apart  from  the  ac- 
tual contact  points  of  the 
occlusion,  and  thus  pre- 
vent them  from  being 
caught  and  pinched,  or 
crushed,  between  the 
teeth  in  the  act  of  masti- 
cation. In  youth,  while 
the  permanent  teeth  are 
taking  their  places,  and 
before  the  cusps  are  prop- 
erly fitted  to  the  sulci,  we  often  find  the  cheeks  or  tongue  wounded  by  being  caught 
between  false  occluding  points.  With  the  after  movements  of  the  teeth,  by  which 
they  are  more  perfectly  arranged,  this  difficulty  disappears. 

"The  line  from  before  backward  on  which  the  occlusion  occurs  is  not  quite 
a  plane;  in  the  lower  jaw  it  presents  a  slight  curve,  or  concavity,  and  in  the  upper 
jaw  a  convexity  (Fig.  6,  c  to  d).  The  concavity  of  the  Hne  of  the  occluding  sur- 
faces of  the  lower  teeth  is  a  little  greater  than  the  convexity  of  the  upper,  so  that 
the  cutting  edges  of  the  lower  incisors  pass  a  little  beyond,  and  to  the  lingual  of 
the  cutting  edges  of  the  upper  incisors. 

"In  the  occlusion,  the  relative  mesio-distal  position  of  the  particular  teeth 
of  the  upper  jaw  to  the  lower  is  important  (Fig.  6).  At  their  cutting  edges  the 
upper  central  incisors  are  about  one-third  wider  from  mesial  to  distal  than  the 
lower  centrals.  The  upper  central,  therefore,  occludes  with  the  lower  central, 
and  also  with  from  one-third  to  one-half  of  the  lower  lateral  incisor.  The  upper 
lateral  occludes  with  the  remaining  portion  of  the  lower  lateral,  and  the  mesial 
portion  of  the  lower  cuspid.  The  upper  cuspid  is  usually  rather  broader  from 
mesial  to  distal  than  the  lower,  and  in  occlusion  covers  its  distal  two-thirds  and 
about  half  of  the  lower  first  bicuspid  so  that  its  lingual,  or  triangular  ridge,  is 
between  the  cusp  of  the  lower  cuspid  and  the  buccal  cusp  of  the  lower  first  bicuspid, 
the  point  of  its  cusp  overlapping  the  lower  teeth.  The  buccal  cusp  of  the  lower 
first  bicuspid  occludes  in  the  space  between  the  upper  cuspid  and  the  upper  first 
bicuspid.  This  order  is  now  maintained  between  the  bicuspids.  The  buccal 
cusp  of  the  upper  first  bicuspid  overlaps  (to  the  buccal)  the  space  between  the 
two  lower  bicuspids,  and  its  lingual  cusp  occludes  in  the  sulcus  between  them, 
while  the  buccal  cusp  of  the  lower  second  bicuspid  occludes  in  the  sulcus  between 


64  PART   in.     BASIC   PRINCIPLES  OF   PRACTICE 

tlie  two  iii)p(.T  bicuspids.  The  cusps  of  the  upper  second  bicuspid  occlude  between 
the  lower  second  bicuspid  and  lower  first  molar.  The  broad  surfaces  of  the  molars 
come  together,  so  that  the  mesial  two-thirds  of  the  upper  first  molar  covers  the 
distal  two-thirds  of  the  lower  first  molar;  and  the  distal  third  of  the  upper  first 
molar  covers  the  mesial  third  of  the  lower  second  molar.  This  brings  the  trans- 
verse ridge  of  the  upper  molar  between  these  two  lower  teeth.  This  order  is 
continued  between  the  remaining  molars,  but  less  perfectly  as  the  teeth  are  more 
irregularly  formed.  The  upper  third  molar  is  usually  smaller  than  the  lower  third 
molar,  yet  it  generally  extends  over  its  distal  surface. 

"The  inclination  of  the  teeth  is  the  deviation  of  their  long  axes  from  the  per- 
pendicular line.  The  direction  of  the  inclination  is  expressed  by  some  accom- 
panying word.  The  upper  incisors  and  cuspids  are  so  arranged  that  their  crowns 
are  inclined  more  or  less  forward,  or  towards  the  lip,  and  slightly  towards  the 
median  line.  The  mesial  inclination  is  continued  in  the  bicuspids  and  molars, 
diminishing  from  before  backward,  and  is  usually  lost  at  the  second  or  third 
molar.  As  a  rule,  the  bictispids  and  molars  of  the  upper  jaw  are  also  slightly 
inclined  towards  the  cheek,  but  in  many  dentures  this  inclination  is  slight,  or 
wanting  in  the  bicuspids  and  first  molars,  to  re-appear  in  tlie  second  and  third 
molars,  though  it  may  be  absent  even  in  these  without  necessary  malformation. 

"The  lower  incissors  and  cuspids  are  also  inclined  with  their  crowns  towards 
the  lip,  but  in  less  degree  than  the  upper.  And  even  the  perpendicular  position 
of  these  is  not  inconsistent  with  a  normal  arrangement.  They  have,  however, 
a  mesial  inclination,  but  usually  much  less  than  the  corresponding  upper  teeth. 
The  lower  bicuspids,  within  the  limits  of  the  normal  arrangement,  vary  consider- 
ably in  their  inclinations.  Sometimes  they  have  a  strong  mesial  inclination,  and 
at  other  times  they  are  nearly  or  quite  perpendicular.  In  many  dentures,  they 
also  have  a  lingual  inclination,  but  may  be  perpendicular  or  even  have  a  slight 
buccal  inclination.  The  lower  molars  usually  have  a  slight  mesial  and  lingual 
inclination.  In  many  examples,  however,  the  mesial  inclination  is  wanting, 
especially  in  the  second  and  third  molars. 

"All  the  teeth  are  a  little  broader  from  mesial  to  distal  at  or  near  the  occlud- 
ing surfaces  than  at  their  necks.  Therefore,  when  aiTanged  in  the  arch  with 
their  proximate  surfaces  in  contact,  there  is  a  considerable  space  between  their 
Fig.  10.  necks  (Fig.  6).     These  are  known  as  the  inter- 

^^■^-'•S^^».  ^^        proximate,  or  V-shaped,  spaces.   The  sharp  angle 

or  apex  of  the  V-form  is  tow'ard  the  occluding 
surface  or  at  the  contact  point  of  the  proxima- 
tion,  and  the  open  end  or  base  is  at  the  crest  of 
the  alveolar  process.  In  normal  conditions,  this 
space  is  filled  by  the  soft  tissues,  or  gums  (Fig.  10).  The  average  arch  measures 
about  127  millimeters  (5  inches)  from  the  distal  surface  of  the  right  third  molar 
to  the  distal  surface  of  the  left  third  molar,  following  the  curve  of  the  arch.    This 


CHAPTER   IX.     ARRANGEMENT  OF   THE   TEETH  65 

represents  the  average  mesio-distal  measurement  of  the  crowns  of  the  teeth  of  the 
upper  jaw  taken  collectively.  The  average  measurement  of  the  teeth  at  their 
necks  is  about  89  millimeters  (3.5  inches).  The  remaining  38  millimeters  (1.5 
inches)  represent  the  average  sum  of  the  interproximate  spaces  taken  collectively. 

"On  account  of  the  difference  in  the  conformation  of  the  crowns  and  the  in- 
clination of  the  teeth,  the  interproximate  spaces  vary  much  in  width  in  different 
dentures.  They  are  much  wider  between  bell-crowned  teeth  than  between  thick- 
necked  teeth;  but  some  interproximate  space  exists  in  every  normal  denture. 
When  the  crowns  of  the  incisors  and  cuspids  are  much  inclined  towards  the  lip, 
the  necks  of  the  teeth  form  a  smaller  circle  than  the  line  of  the  contact  points 
of  the  proximation,  and  in  this  way  the  interproximate  spaces  may  be  consid- 
erably narrowed.  Generally,  the  interproximate  space  is  wide  between  the  necks 
of  the  central  incisors.  The  suture  joining  the  maxillary  bones  passes  between 
the  roots  of  these  teeth,  and  they  are  somewhat  farther  apart  than  the  roots  of 
the  central  and  lateral  incisors,  or  those  of  the  lateral  incisor  and  the  cuspid. 
Therefore,  in  these  latter,  the  interproximate  spaces  are  of  less  width.  Between 
the  bicuspids  the  interproximate  spaces  are  wider  at  the  necks  of  the  teeth  than 
between  the  anterior  teeth,  on  account  of  the  greater  breadth  of  the  crowns  as 
compared  with  the  roots.  The  widest  interproximate  spaces  are  usually  between 
the  necks  of  the  molars. 

"The  points  of  proximate  contact  in  the  best  formed  arches  are  near  the  oc- 
cluding surfaces  of  the  teeth.  In  imperfectly  developed  teeth,  in  which  the  crowns 
are  much  rounded  towards  the  occluding  surfaces,  the  contact  points  are  more 
toward  the  gingival.  In  the  incisors  and  cuspids  they  are  in  direct  line  with  the 
cutting  edges.  In  the  bicuspids  the  contact  is  near  the  buccal  angles  and  nearly 
in  line  with  the  buccal  cusps. 

"The  mesial  and  distal  flattened  surfaces  of  these  teeth  converge  to  the  lingual 
to  such  an  extent  that,  thovigh  they  are  arranged  in  arch  form,  the  contact  points 
remain  close  to  the  buccal  angles.  In  many  excellent  dentures  there  is  a  decided 
interproximate  space  opening  to  the  lingual,  but  in  thick-necked  teeth  and  those 
of  a  more  rounded  contour  the  contact  points  are  often  more  toward  the  lingual, 
and  there  is  no  appreciable  lingual  interproximate  space.  In  the  molars  the  contact 
points,  as  a  rule,  are  removed  rather  more  to  the  Hngual,  but  still  in  the  best  formed 
dentures  they  will  be  found  nearly  in  line  with  the  buccal  cusps.  Between  the 
upper  first  and  second  molars  the  contact  point  is  often  extended  toward  the  lingual 
by  the  prominent  disto-lingual  cusp  of  the  first  molar;  and,  even  when  otherwise 
the  general  rounding  of  the  distal  surfaces  of  the  upper  molars  often  brings  the  con- 
tact points  near  the  middle  Une  of  the  teeth.  In  lower  first  molars  the  large  distal 
cusp  brings  the  contact  point  with  the  second  molar  close  to  the  buccal  side, 
with  a  considerable  lingual  intei-proximate  space.  If  the  distal  cusp  is  small 
the  contact  point  is  usually  extended  toward  the  lingual,  often  as  far  as  half  the 
bucco-lingual  breadth  of  the  teeth.     Between  the  second  and  third  molars  the 


66 


PART    III.     BASIC    I'RIXCII'LF.S   ()/■    PRACTICE 


contact  point  is  most  fn'ciucntly  near  tlic  central  line  of  the  teeth.  In  the  best 
formed  dentures  the  form  of  the  proximate  contact  is  such  as  to  prevent  food  from 
Ijeinj;  crowded  between  the  teeth  in  mastication;  and,  therefore,  such  as  to  keep 
these  spaces  clean  and  the  interproximate  gingivus  in  health.  But  many  faulty 
forms  are  met  with,  which  allow  food  to  leak  through  into  the  interproximate  space 
and  crowd  the  gum  away,  forming  a  pocket  for  the  lodgment  of  debris,  giving 
opportunity  for  decomposition,  and  resulting  in  caries  of  the  proximate  surfaces, 
or  disease  of  the  gum  and  peridental  membrane.  Exceptionally,  cases  are  met 
with  in  which  the  teeth  stand  so  widely  apart  that  the  spaces  are  self-cleaning.  The 
form  of  the  interproximate  spaces  is  very  variable.  It  is  best  studied  in  skulls  in 
which  the  teeth  are  all  present,  and  by  careful  consideration  of  the  forms  of  the 
proximate  surfaces  of  the  teeth,  together  with  their  relative  pf:)siti(.)ns. 


THE  ALVEOLAR  PROCESS  AND  ALVEOLI 


Fic.  11. 


Fig.  12. 


"The  alveolar  process  is  the  projecting  portion  of  the 
maxillary  bones  within  which  the  roots  of  the  teeth  are  lodged 
in  alveoli,  or  sockets,  accurately  fitted  to  their  surfaces  (Figs. 
11  and  12).  The  form  of  the  alveolar  process  seems  to  depend 
on  the  teeth,  the  conformation  of  their  roots,  and  their  ar- 
rangement in  the  arch.  If  any  teeth  are  misplaced,  or  from 
any  cause  stand  out  of  the  regular  and  normal  line,  the  alveolar 
process  is  formed  about  their  roots  in  this  irregular  position. 
Also,  when  teeth  are  lost,  the  alveolar  process  mostly  disap- 
pears by  absorption,  and  the  remaining  portions  of  the  alveoli 
are  filled  with  bone. 

"Normally,  the  alveolar  process  envelops  the  roots  of  the 
teeth  to  within  a  short  distance  of  the  gingival  line  (Figs.  6 
and  13),  varying  from  one  to  three  millimeters  in  the  young 
adult.  This  distance  increases  somewhat  with  increasing  age. 
The  borders  of  the  alveolar  process  are  reduced  to  a  thin  edge 
about  the  necks  of  the  teeth  on  both  the  labial  and  lingual 
sides  of  the  incisors  and  cuspids  of  the  upper  jaw.  About 
the  lingual  sides  of  the  necks  of  the  bicuspids  and  molars  the 
borders  are  also  reduced  to  a  thin  edge,  becoming  slightly 
thickened  about  the  second  and  third  molars,  especially  of 
the  latter.  On  the  buccal  sides  of  these,  a  thickening  of  the 
immediate  borders  of  the  alveolar  process,  in  the  form  of  a 
marked  ridge,  begins  about  the  first  or  second  bicuspid,  more  commonly  between 
these  two,  and  extends  to  the  distal  of  the  third  molar  (Fig.  6,  a).  This  ridge 
varies  in  different  examples,  from  a  very  slight  thickening  of  the  immediate  border, 
to  a  thickness  of  two  or  three  millimeters.     It  forms  a  border  standing  squarely 


CHAPTER   IX.     ARRANGEMENT  OF   THE   TEETH 


67 


out  from  the  necks  of  the  teeth.     The  alveolar  process  then  thins  away  so  that,  in 

many  instances,  the  buccal  roots  of  the  teeth,  especially  the  mesial  root  of  the 

Fig.  13.  first  molar,  have  but  a  thin  covering  of  bone. 

"Anteriorly,  the  bony  covering  of  the 
roots  of  the  upper  incisors  presents  much 
variety.  In  some  examples,  the  middle  por- 
tion of  the  roots  has  but  a  slight  covering  of 
bone,  but  more  generally  it  is  progressively 
thickened  from  the  neck  to  the  apex.  The 
roots  of  the  cuspids  are  prominent  towards 
the  lip,  and,  for  most  of  their  length,  have 
only  a  thin  bony  covering,  and  this  forms  a 
ridge  along  the  line  of  the  root,  which  may 
easily  be  traced  with  the  finger  through  the 
soft  tissues  of  both  the  gum  and  lip.  In 
many  instances  the  bony  covering  is  entirely 
wanting  for  a  little  space  near  the  middle 
of  the  length  of  the  root  of  the  cuspid,  the  buccal  root  of  the  first  bicuspid,  the 
mesial  root  of  the  first  molar,  and,  occasionally,  of  other  teeth. 

"On  the  lingual  side  of  the  upper  teeth  (Fig.  13),  the  progressive  thickening  of 
the  alveolar  process,  from  the  border  towards  the  apex  of  the  root,  is  much  greater; 
so  that  the  roots  of  the  teeth  seem  to  lie  towards  the  labial  and  buccal  side  of  the 
alveolar  process  (Fig.  11).  Even  the  large  lingual  root  of  the  upper  first  molar, 
diverging  strongly  to  the  lingual,  seldom  forms  a  ridge  or  prominence  of  the  proc- 
ess covering  its  ling-aal  surface." 


CHAPTER  X 

"TYPICAL  AND   ATYPICAL   OCCLUSION   OF   THE   TEETH   IN   RELATION   TO 
THE    CORRECTION    OF    IRREGULARITIES" 

The  following  chapter  is  an  extract  from  a  paper  entitled  as  above,  by  Dr. 
Matthew  H.  Cryer,  Professor  of  Oral  Surgery  in  the  L''^niversity  of  Pennsylvania, 
read  before  the  New  York  State  Dental  Society,  May,  1904,  and  published  in  the 
Dental  Cosmos,  September,  1904. 

It  should  be  carefully  studied  in  its  general  and  scientific  teaching  of  the 
anatomical,  physiological,  and  surgical  aspects  of  the  teeth  in  relation  to  Ortho- 
dontia. The  teachings  of  men  of  Dr.  Cryer's  long  experience  and  eminence  in 
the  dental  profession,  relative  to  the  principles  of  tooth  niovement  and  regula- 
tion, should  receive  the  profoundest  consideration.  Attention  is  particularly 
called  to  his  opinions  in  regard  to  some  pha.ses  of  the  much  exploited  theory 
of  regulating  all  cases  without  extraction,  upon  the  basis  that  "the  most  esthetic 
facial  outlines  are  dependent  upon  the  production  of  a  typically  normal  occlusion." 

EXTRACT  FROM  DR.  CRYER'S  PAPER 

"During  the  past  three  years  many  papers  have  been  published  on  the  subject 
of  irregularities  of  the  teeth  and  their  treatment,  and  while  some  of  them  are  of 
unquestionable  value,  covering  points  of  capital  importance  in  the  field  of  Ortho- 
dontia, the  author  feels,  however,  that  due  consideration  has  not  always  been 
given  to  the  outlines  of  the  face  which  are  molded  upon  the  topographical  anatomy 
of  the  facial  bones,  the  alveolar  processes,  and  the  teeth. 

"Some  writers  have  given  fixed  rules  for  changing  the  position  of  the  teeth, 
without  bearing  in  mind  the  fact  that  each  case  demands  the  adoption  of  a  special 
mode  of  procedure  in  its  treatment.  This  wholesale  correction  by  rule  is  causing 
many  of  the  young  members  of  the  profession  to  perform  operations  which  are 
damaging  to  the  patient  and  which  cannot  be  rectified  in  later  years.  It  is  for 
this  reason  that  the  writer  desired  to  present  a  paper  which  would  bring  out  a 
general  discussion  upon  'Typical  and  Atypical  Occlusion  of  the  Teeth.' 

"In  the  correction  of  irregularities  of  the  teeth  and  their  processes,  three 
fundamental  principles  should  always  be  considered.  First,  the  operator  should 
carefully  regard  the  outlines  of  the  face,  especially  as  they  should  appear  in  early 
adult  life;  the  dift'erence  in  treatment  demanded  by  the  male  and  female  type 
should  be  observed;  the  variations  in  each  individual  should  be  considered,  and 
each  case  treated  according  to  its  own  requirements.     Second,  due  consideration 

68 


CHAPTER   X.     TYPICAL   AND   ATYPICAL  OCCLUSION  OF   THE   TEETH  69 

should  be  given  to  the  appearance  of  the  teeth  when  the  lips  are  open,  as  in  talking 

and  laughing.      Third,   the  importance  of  occlusion  in  regard  to  vocalization, 

appearance,  and  mastication.     As  malocclusion  often  brings  serious  pathological 

conditions,  such  as  impacted  teeth,  neuralgia,  etc.,  this  condition  should  receive 

most  careful  attention.     It  is  the  writer's  opinion  that  the  surgeon  should  have 

a  full  knowledge  of  the  superficial  and  internal  anatomy  of  the  maxillary  bones, 

with  that  of  the  alveolar  process,  which  is  only  the  connecting  structure  between 

the  teeth  and  the  bones  proper.     He  should  also  be  thoroughly  conversant  with 

the  physiology  of  this  region  and  with  the  pathological  changes  of  which  it  may 

become  the  seat. 

Typical  vs.  Actual  Anatomy  and  Occlusion 

"After  close  study  of  the  forms  of  various  bones  of  the  human  skeleton,  both 
disarticulated  and  articulated,  and  the  open  spaces  of  the  face,  such  as  the  oral 
cavity,  the  orbits,  the  nasal  chamber  with  its  associated  pneumatic  sinuses  and 
cells,  etc.,  the  writer  came  to  the  conclusion  that  typical  anatomy  as  taught  in 
textbooks  is  more  ideal  than  true,  and  is  something  different  from  that  with  which 
the  surgeon  comes  into  daily  contact,  and  it  is  his  opinion  that  this  divergence 
applies  to  a  notable  extent  in  reference  to  the  jaws  and  teeth  at  rest  and  in  occlusion. 

"In  order  to  bear  out  this  statement  a  few  illustrations  will  be  given  showing 
the  typical  anatomy  of  the  external  and  internal  structures  of  the  jaws  and  the 
occlusion  of  the  teeth. 

Fig.  14. 


Upper  and  lower  jaws  of  a  negro  skull,  showing  considerable 
prognathism. 


"The  illustration  Fig.  14  is  from  a  slide  kindly  loaned  by  Dr.  I.  N.  Broomell, 
from  a  photograph  of  a  negro  skull  which  is  in  his  possession.  The  reason  for 
showing  this  picture  is  the  fact  that  various  authors  give  it  as  an  illustration  of 
normal  occlusion  of  the  teeth,  omitting  to  state  that  it  is  from  the  negro  race — in 


70  /'.IA'7-    ///.     A'.l.SVC   J'h'/.XCl/'LES  Of   J'RACTfCE 

other  words,  that  it  Ijclongs  to  a  race  more  or  less  prognatliic.  Tlie  ocehision  of 
the  anterior  teeth  shows  that  it  belongs  to  this  type  of  skull;  it  is  a  fine  specimen, 
except  that  the  n])per  secnn<l  and  third  molars  do  not  occlude  typically  with  the 
lower  third  molars,  even  according  to  the  negro  type. 

"Fig.  15  is  a  side  view  made  from  an  almost  perfect  skull  of  a  white  woman. 
The  teeth  are  so  nearly  typical  in  occlusion  that  but  a  few  persons  have  found 
any  fault  with  the  specimen.     The  incisor  teeth  may  possibly  protrude  too  much 

Fio.  15. 


Side  view  of  upper  and  lower  jaws  of  a  Caucasian  skull,  showing  typical  occlusion 
of  the  teeth. 


to  be  in  harmony  with  some  Caucasian  faces.  The  teeth,  especially  the  anterior 
ones,  must  be  in  harmony  with  the  general  outline  of  the  face  and  lips.  In  the 
general  occlusion  it  will  be  found  that  each  tooth  of  the  upper  jaw  comes  into 
contact  with  two  teeth  of  the  lower  jaw,  except  the  third  molar,  while  each  tooth 
of  the  lower  jaw  comes  into  contact  with  two  of  the  upper  teeth,  except  the  cen- 
tral incisors.    The  interlocking  of  the  premolars  and  the  molar  teeth  is  ideal. 

"Some  orthodontists  speak  of  moving  the  teeth  inward,  outward,  forward, 
or  backward,  as  though  they  were  dealing  with  plain  porcelain  teeth  set  up  in 
wax  on  a  mechanical  articulator,  without  taking  into  consideration  the  anatomy, 
physiology,  or  pathological  conditions  presented  in  the  jaws  or  the  general  system. 

"The  writer  can  readily  understand  how  teeth  can  be  moved  forward,  as  a 
rule,  by  orthodontists,  as  that  is  the  direction  of  their  general  or  usual  movement 
during  development  or  eruption  into  their  proper  positions.  But  he  doubts  the 
ability  of  any  man  to  successfully  move  a  lower  first  molar  backward  half  its  width 


CHAPTER   X.     TYPICAL   AXD   ATYPICAL  OCCLUSION  OF   THE   TEETH 


71 


when  the  other  molars  are  in  position.  It  may  be  possible  —  though  it  is  some- 
what doubtful  —  for  the  lower  first  molar  to  be  moved  half  its  width  backward  in 
the  mouth  of  a  child  about  seven  or  eight  years  of  age,  but  ^-our  essayist  fears  serious 
results  even  in  such  a  case. 

Fn,.  l(i. 


Side  view  of  the  upper  and  lower  iaws  ot  a  child  about  seven  or 
eight  years  of  age.  showing  the  deciduous  teeth,  the  first 
molars,  and  the  germs  of  other  permanent  teeth. 


"Fig.  16  is  from  a  specimen  of  jaws  belonging  to  a  child  seven  or  eight  years 
old.  We  find  all  the  decidtious  teeth  in  position,  also  the  first  molar.  The  de- 
veloping crown  of  the  second  molar  is  just  posterior  to  it.  The  germ  of  the  third 
molar  is  not  shown.    Suppose  it  were  possible  to  move  the  first  molar  backward 


Fig.  17. 


/<*r>, 


Side  view  of  upper  and  lower  jail's  of  a  child  about  twelve  or 
thirteen  years  of  age. 


72 


PMir   III.     BASIC   PRINCIPLES  OF   PRACTICE 


half  its  width,  would  it  not  interfere  very  materially  with  the  second  molar  by 
disturbing  its  true  position — -by  carrying  it  backward  and  turning  it  over  to  a 
greater  or  less  extent? 

"Fig.  17  is  from  a  similar  preparation,  of  a  child  about  twelve  or  thirteen 
years  of  age.  If  the  first  molar  had  been  moved  backward  half  its  width,  at 
the  age  of  seven  or  eight  years,  the  second  molar  would  have  been  carried  back 
with  it.  This  would  not  have  allowed  proper  space  for  the  third  molar,  which 
would  more  than  likely  have  become  impacted. 

Fig.  is. 


From  a  radiograph  taken  from  a  cleaned  specimen  of  the  left  side  of  the  lower  ja 
showing  an  impacted  third  molar. 


"Fig.  18  is  a  radiograph  taken  from  a  cleaned  specimen  of  the  left  side  of  the 
lower  jaw  showing  the  teeth  in  their  position  with  the  cancellated  tissue.  One 
might  well  imagine  that  a  modern  orthodontist  had  moved  the  first  molar  half 
its  width  backward  or  held  it  in  such  a  manner  that  it  could  not  advance.  Whether 
this  was  done  by  a  mechanical  appliance  or  was  the  result  of  pathological  causes, 
the  tooth  was  held  and  impaction  resulted.  If  the  cancellated  tissue  be  examined, 
as  seen  in  the  X-ray  picture,  it  will  be  noticed  that  it  is  more  dense  around  the  first 
and  second  molars  than  anteriorly  to  these  teeth.  As  the  result  of  an  inflammatory 
condition  the  cancellated  tissue  has  become  united  with  the  cortical  bone,  thus 
making  another  factor  in  preventing  its  sliding  forward.  It  will  be  noticed  that  the 
roots  of  the  molar  teeth  are  also  thickened  by  the  overaction  of  the  cementoblasts 
caused  by  this  inflammatory  condition. 


CHAPTER   X.     TYPICAL   AND  ATYPICAL  OCCLUSION   OF    THE   TEETH 


73 


Extraction  for  the  Correction  of  Irregularities 

"Many  writers,  especially  of  late,  claim  that  irregularities  of  the  teeth  should 
always  be  corrected  without  the  extraction  of  one  or  more  teeth,  as  'Nature  never 
puts  teeth  into  a  mouth  that  do  not  belong  to  that  physiognomy.'  Your  writer 
thinks  this  is  doing  Natvire  a  great  injustice;  many  teeth  are  found  within  the 
mouth  which  should  be  removed,  not  only  for  the  correction  of  irregularities 
but  for  the  general  comfort  and  health  of  the  patient.  Modem  civilization  de- 
mands that  we  live  contrary  to  rather  than  in  accordance  with  Nature,  and  so 
long  as  this  is  so,  we  cannot  blame  Nature  for  existing  irregularities  or  depend 
entirely  upon  her  for  beneficent  results.  Our  numerous  dental  and  medical  col- 
leges testify  to  the  necessity  of  assisting  Nature  to  bscome  reconciled  with  modern 
methods  of  living. 

Fig.  19. 


Made  from  two  upper  jaws,  showing  a  large  amount  of  tooth  tissue  in  the  smaller  jaw,  A,  and  much 

less  in  the  larger  jaw.  B. 

"Fig.  19  is  made  from  two  photographs  of  upper  jaws  taken  on  the  same 
plate.  These  pictures  are  to  demonstrate  that  a  small  jaw  can  be  crowded  with 
large  teeth,  while  a  large  jaw  may  have  small  teeth  with  space  between  them. 
It  has  been  given  as  a  reason  for  this  condition  that  a  child  may  inherit  the  jaw 
of  one  parent  and  the  teeth  of  another,  and  for  lack  of  a  better  explanation  it  may 
be  well  to  accept  this  one  for  the  present. 

"From  a  practical  standpoint  it  matters  not  why  such  irregularities  exist; 
they  are  there,  and  must  be  corrected.  Notice  the  size  of  the  teeth  in  the  left 
picture.  Beginning  with  the  incisors  and  passing  backward,  the  first  bicuspid 
is  extraordinarily  large,  as  are  also  the  molar  teeth ;  there  seems  to  be  too  much 
tooth  tissue,  as  in  addition  two  rudimentary  fourth  molars  can  also  be  seen. 
What  would  the  non-extractor  do  with  these  two  teeth?  Would  he  endeavor  to 
place  them  in  their  regular  position,  as  shown  in  the  illustration  Fig.  23,  or  would 
he  not  rather  acknowledge  that  these  teeth  should  be  extracted  because  they 
interfere  with  the  general  hygiene  of  the  mouth? 

"Fig.  20  is  a  lateral  view  of  the  left  picture  of  Fig.  19.  The  teeth  are  in  occlu- 
sion with  its  mate,  the  lower  jaw.    It  has  been  claimed  by  many  that  if  the  first 


74 


PART   TJI.     BASIC   PRiyClPI.KS  OF    PRACTICE 


molars  or  bicuspids  be  properly  locked,  the  other  teeth  would  be  in  good  occlusion. 
The  writer  cannot  agree  with  these  two  assertions.  The  illustration  before  us  shows 
that  the  first  and  second  molars  of  each  jaw  are  typical  in  occlusion  as  well  as  the 
bicuspids.  (The  molars  and  bicttspids  on  the  opposite  side  are  in  equally  good 
occlusion.)     If  the  above  rviles  are  to  be  followed,  then  the  canine  and  incisor 

Fig.  20. 


Upper  and  luwcr  ]:ius  m 

teeth  should  be  correct,  but  they  are  not  to  be  found  so  in  the  skull  from  which 
this  illustration  was  taken.  The  incisors  are  in  occlusion,  edge  to  edge,  instead 
of  the  upper  one  overlapping  the  lower  one.  A  large  amount  of  tooth  tissue  was 
shown  in  the  upper  jaw,  and  a  large  quantity  in  proportion  in  the  lower  jaw.  In 
order  to  have  had  proper  occlusion  it  would  have  been  necessary  to  have  lost  tooth 
tissue  laterally,  in  the  lower  jaw.  If  this  be  granted,  then  the  question  arises, 
when  should  it  have  lieen  lost,  and  what  tooth  or  teeth  should  have  been  extracted? 


Characteristic  Features  of  Caucasian  and  Negro  Skulls 

Fi(.  121. 


A  li 

View  of  the  under  surfaces  of  skulls,  showing  difference  be- 
tween Fan  Tribe  West  African  skull  and  the  Caucasian. 


"Fig.  21  is  made  from  the  under  surface  of  two  skulls.     The  one  on  the  left 
is  that  of  a  Fan  Tribe  West  African,  the  other  is  from  a  Caucasian.     They  differ 


CHAPTER   X.     TYPICAL   A.XD  ATYPICAL  OCCLUSIOX   OF   THE   TEETH 


75 


greatly  in  the  shape  of  the  roof  of  the  mouth  and  the  line  of  the  occluding  sur- 
faces of  the  teeth.  For  these  types  of  skulls  they  are  normal  in  the  arrangement 
of  the  teeth,  with  the  exception  of  those  lost  by  decay.  The  line  of  the  occluding 
surfaces  of  the  white  skull  is  too  nearly  circvilar,  however,  to  be  termed  typical. 
The  special  difference  in  these  skulls  is  this:  In  the  negro,  if  the  outer  line  of  the 
zygomatic  arch  be  carried  around  until  it  intersects  the  teeth,  that  line  will  be 
near  the  anterior  surface  of  the  second  molars;  while  in  the  other  skull  the  line 
would  be  in  front  of  the  first  molar,  showiiig  that  the  teeth  are  carried  forward 
in  the  negro  skull  the  width  of  a  molar  tooth. 

Fig.  22. 


Two  mandibles  —  A.  from  a  Fan  Tribe  West  African  negro;  B.  from  a  Cau- 
casian, showing  difference  in  position  of  teeth  relative  to  the  ramus,  mental 
foramen,  and  symphysis  menti. 


"Fig.  22  is  made  from  two  mandibles.  The  upper  one  is  from  the  same  Fan 
Tribe  negro  as  shown  in  Fig.  21;  the  lower  one  is  from  another  Caucasian  skull. 
If  the  position  of  the  third  molar  of  the  negro  jaw  be  examined,  it  will  be  seen  that 
there  is  room  for  another  molar  back  of  the  third,  while  in  the  mandible  of  the  white 
skull  the  third  molar  is  far  back,  leaving  no  room  for  another  tooth.  In  the  negro 
jaw  the  mental  foramen  will  be  found  below  the  first  molar,  while  in  the  white 
jaw  it  is  on  a  line  drawn  downward  from  between  the  bicuspids,  showing  again  that 
in  the  negro  skull  the  teeth  are  carried  forward  about  the  width  of  a  molar  tooth. 


76 


PART   III.     BASIC   PRIM'IPLI-S  OF   PRACnCE 


Side  view  of  a  prognathous  negro  skull  with  eighteen 
teeth  in  the  upper  jaw. 

"Fig.  23  is  from  the  skv:ll  of  another  negro  who  died  while  in  the  Philadelphia 
Hospital.  The  prognathism  is  not  so  marked  as  in  the  one  belonging  to  the  Fan 
Tribe  West  African.  The  mental  foramen  in  this  case  is  situated  on  a  line  between 
the  second  bicuspid  and  the  first  molar.  In  the  upper  jaw  there  are  eighteen 
teeth,  the  two  most  distal  being  rudimentary  fourth  molars.  Barring  these  fourth 
molars,  all  the  other  teeth  are  in  good  occlusion.  If  this  condition  of  the  teeth 
were  exhibited  in  the  white  race,  which  would  give  the  appearance  of  that  shown 
in  the  next  figtire,  it  would  be  good  surgery  to  remove  the  upper  and  lower  bicuspids 
or  the  upper  and  lower  first  molars  on  each  side. 

Prognathous  Appearance  Caused  by  Hypertrophied  Gums 
AND  Alveolar  Processes 

"Not  having  an  anatomical  specimen  showing  this  kind  of  prognathism, 
your  essayist  has  taken  the  liberty  to  show  Fig.  24,  which  was  made  from  the 


Ft.. 


From  photograph  ni  a  iad  sutienn^;  tri>ni  n\|n.- 
gums  and  alveolar  process. 


■  of  the 


CHAPTER   X.     TYPICAL   AND  ATYPICAL   OCCLUSION  OF   THE   TEETH 


1 1 


photograph  of  a  boy  about  fifteen  years  old.  When  this  picture  was  shown  to 
one  of  our  leading  orthodontists,  he  declared  it  was  that  of  a  degenerate.  The 
boy  had  a  most  marked  hypertrophied  condition  of  the  gums  and  alveolar  process 
of  both  jaws,  which  protruded  forward.  It  was  thought  advisable  to  remove 
the  alveolar  process  along  with  the  teeth  and  gvims,  which  gave  him  the  appear- 
ance shown  in  the  next  picture. 


Fig. 


Fig.  2(1 


From  photograph  taken    three  weeks  after  removal  of    the 
pathological  tissue. 


From  photograph  taken  five  years  after 
operation  upon  the  person  represented  in 
Fig.  24. 


"Fig.  25  was  taken  three  weeks  after  the  operation.  The  prognathism  is  lost, 
leaving  somewhat  sunken  cheeks. 

"Five  years  afterward  he  had  a  picture  taken  shown  in  Fig.  26.  No  one  would 
claim  that  this  picture  was  that  of  a  degenerate. 

"These  last  three  illustrations  have  been  exhibited  in  order  to  justify  the 
removal  of  gum,  tooth,  and  alveolar  tissue,  or  even  bone,  to  correct  such  deformi- 
ties, even  if  artificial  teeth  have  to  be  worn  afterward." 


CHAPTER  XI 

DENTO-FACIAL   PRINCIPLES   OF   OCCLUSION    WITH    REFERENCE 

TO   PRACTICE 

As  a  number  of  prominent  orthodontists  are  still  following  the  teaching  that  a 
normal  occlusion  should  be  regarded  as  the  indispensable  standard  of  attainment 
in  the  correction  of  all  cases  of  malocclusion,  it  is  important  that  students,  while 
being  taught  to  appreciate  its  full  value  should  also  be  prevented  from  overestimat- 
ing its  limitations  as  a  basic  principle  in  diagnosis  and  treatment. 

Occlusal  Relations. — In  the  correction  of  all  malocclusions  of  the  teeth  with  a 
view  to  their  future  permanency  of  retention,  occlusion  and  dento-facial  relations 
are  the  most  important  factors  for  consideration  in  diagnosis  and  treatment. 

In  every  case  where  the  masticating  teeth  have  established  a  fixed  occluding 
position  with  cusps  that  interlock  or  interdigitate,  whether  or  not  it  be  typically 
normal  in  its  relations,  any  change  of  that  position  necessary  for  the  accomplish- 
ment of  correction  should  place  them  in  a  neiv  occlusal  adjustment  of  self-fixation; 
otherwise,  nature  either  in  her  forceful  efforts  to  perfect  the  function  of  mastication, 
or  in  response  to  the  law  of  heredity,  will  mar  or  wholly  destroy  the  perfect  results 
of  treatment,  even  though  they  be  artificially  retained  for  years. 

In  cases  where  one  or  more  teeth  of  either  jaw  are  crowded  out  of  arch  align- 
ment, or  are  malturned  and  overlapping,  if  held  in  that  malposition  by  the  fixed 
occlusion  of  other  teeth,  any  movement  to  accommodate  them  that  is  destined  to 
affect  the  relative  positions  of  the  premolars  or  molars  will  usually  require  a  con- 
comitant movement  of  the  occluding  teeth  of  the  opposing  jaw. 

In  a  large  proportion  of  malocclusions  among  youths  whose  inherited  disto- 
mesial  relations  of  the  buccal  teeth  were  normal,  there  will  be  found  no  marked 
abnormal  dento-facial  disharmony;  and  even  those  facial  imperfections  that  are 
caused  by  a  malrelation  of  the  teeth  in  occlusion,  will  frecjuently  disappear  upon 
proper  corrective  treatment  after  being  followed  by  the  harmonizing  influences  of 
growth.  Therefore,  in  all  of  these  cases,  however  jumbled  the  irregularity,  the  rule 
should  be  imperative  that  we  strive  to  produce  a  typically  normal  occlusion. 

This  does  not  mean  that  the  principal  and  only  object  in  practice  in  all  cases  is 
to  attain  to  the  production  of  a  normal  occlusion  at  the  expense  of  producing  or 
retaining  a  facial  deformity;  and  especially  if  by  the  extraction  of  the  first  or 
second  premolars  we  can  place  the  operation  within  sure  and  easy  possibilities  of 
correcting  the  facial  deformity  and  leave  the  patient  with  a  good  masticating  oc- 
clusion— often  so  perfect  that  only  an  expert  is  able  to  discover  that  teeth  are  miss- 
ing.    Nor  does  it  mean  that  the  correction  of  the  facial  deformity  or  imperfection 

78 


CHAPTER   XI.    PRINCIPLES  OF  OCCLUSION  79 

should  be  accomplished,  if  possible,  at  the  expense  of  a  masticating  occlusion 
whose  cusps  interdigitate.  One  is  quite  as  important  as  the  other.  The  facial 
outlines  should  always  be  considered,  because  they  frequently  mark  the  course 
that  should  be  pursued  in  a  correction  of  the  dental  irregularity,  with  the  con- 
comitant correction  of  the  facial  outlines,  as  they  indicate  whether  we  should  move 
the  upper  or  the  lower  teeth,  or  both,  and  also  the  relative  amount  of  movement 
demanded.  They  indicate  also,  whether  it  will  be  inadvisable  to  attempt  correc- 
tion without  extraction.  The  failure  to  extract  teeth  when  demanded,  is  quite 
as  much  malpractice  as  the  extraction  of  teeth  when  not  demanded. 

In  the  contemplation  of  obtaining  room  for  the  correction  of  malposed  teeth, 
or  for  the  freer  eruption  of  the  permanent  teeth  of  youths  by  the  expansion  of  im- 
mature arches,  or  by  the  extraction  of  temporary  or  permanent  teeth,  the  har- 
monizing influences  of  growth  with  the  natural  enlargement  of  the  alveolar  arches 
should  never  be  lost  sight  of.  If  dentists  would  give  more  thought  to  this  subject, 
and  to  the  possibilities  of  judiciously  enlarging  the  arches  in  keeping  with  the  present 
and  future  development  of  other  parts,  there  would  not  be  that  ruthless  and  un- 
called-for interference  and  that  wholesale  malpractice  of  extraction  which  has  so 
often  disgraced  the  science  of  dentistry  in  former  years. 

With  modern  methods  and  principles  of  applying  force  to  the  teeth,  the  dental 
arches  can  always  be  sufficiently  enlarged  to  place  all  the  teeth  in  alignment  and  in 
normal  occlusion  if  demanded,  however  extensively  malposed.  Therefore,  the 
question  of  extraction  should  never  arise  as  a  means  toward  making  an  operation 
easier  or  possible  in  the  correction  of  any  dental  irregularity.  Nor  should  it  ever 
arise,  except  in  cases  of  decided  dento-facial  protrusion  which  cannot  be  corrected 
by  the  most  skillful  methods  toward  placing  the  dentures  in  normal  occlusion.  It 
is  not  always  possible  to  decide  this  question  at  the  beginning  of  an  operation, 
especially  for  young  patients  whose  mature  growth  development  of  other  features 
will  frequently  harmonize  the  facial  relations.  Therefore,  if  the  facial  outlines  show 
no  very  marked  protrusion  of  one  denture,  or  both,  the  safer  way,  at  times  of 
uncertainty  like  this,  would  be  to  place  the  teeth  in  normal  occlusion  subject  to  a 
future  operation  involving  extraction,  if  found  to  be  demanded  for  the  correction  of 
a  resultant  facial  deformity.  Read  the  history  and  study  the  illustrations  of  Fig. 
164,  Chapter  XXIX. 

Every  dentist,  and  especially  those  who  essay  the  regulation  of  teeth,  whether 
he  limits  his  practice  to  this  specialty,  or  not,  should  consider  it  imperative  to 
his  professional  education  to  fully  understand  the  mechanical,  anatomical,  and 
physiological  principles  of  normal  occlusion  of  the  teeth.  In  fact  a  full  apprecia- 
tion of  normal  occlusion  and  all  that  is  implied  by  that  term,  as  a  standard  of  per- 
fection to  imitate  or  strive  for,  has  always  been  one  of  the  greatest  influences  toward 
the  progress  and  development  of  the  science  of  dentistry  and  its  branch,  ortho- 
dontia. One  has  but  to  carefvilly  peruse  the  first  works  of  note  upon  orthodontia 
— "Oral  Deformities,"  by  Dr.  Norman  Kingsley,  pubhshed  in  1880,  and  "Irregu- 


80  PART   J 11.     BASIC  PRINCIPLFS  OF   PRACTICE 

larities  of  Tlie  Tcrth,"  l)y  Dr.  J.N.  Farrar,  published  in  1888 — to  become  convinced 
that  the  importance  of  restoring  teeth  to  a  normal  occlusion  in  orthodontia  was 
fully  appreciated,  and  one  of  the  principal  factors  of  treatment,  by  some  of  the 
leading  minds  then,  as  now.  And  since  that  time  in  all  the  teaching  and  practice 
of  prominent  orthodontists  it  has  been  regarded  as  a  self-evident  principle  in  the 
regulation  and  retention  of  teeth. 

Importance  of  Dr.  Angle's  Teaching. — While  it  is  probably  a  fact  that  the  true 
anatomic  relations  of  normal  dental  occlusion  have  long  been  well  understood  by 
dentists,  and  the  importance  of  striving  for  its  attainment  in  the  correction  of 
irregularities  of  the  teeth  has  been  dwelt  upon  by  numberless  writers  and  pub- 
lished by  dental  journals  and  textbooks,  it  has  nevertheless  remained  for  Dr. 
Edward  H.  Angle  in  his  very  admirable  work  entitled  "Malocclusion  of  the  Teeth," 
to  present  this  phase  of  the  subject  in  so  forcible  a  manner  that  the  dental  profes- 
sion— or  at  least  that  part  of  it  who  essay  the  regulation  of  teeth — have  awakened 
to  a  fuller  appreciation  of  its  importance  as  a  guide  to  correction  and  as  a  means  to 
permanency  of  retention. 

He  places  the  occlusal  relations  of  the  first  permanent  molars  as  the  real  guide- 
posts  in  diagnosis  for  determining  the  general  relations  of  occlusion.  This  should 
meet  with  the  hearty  approbation  of  all  experienced  orthodontists.  First:  Because 
the  occlusal  relations  of  the  first  permanent  molars  are  usually  in  distinct  evidence 
when  other  teeth  which  might  be  used  as  guides  have  not  erupted,  or  are  in  decided 
malalignment.  Second:  The  first  permanent  molars  are  the  true  bases  of  their 
respective  dental  arches,  because  the  relative  antero-posterior  positions  of  other 
teeth  are  largely  influenced  by  the  relative  positions  which  these  teeth  assume  in 
the  jaws.  Third:  With  a  very  large  proportion  of  the  human  family — and  es- 
pecially those  to  whom  abnormal  disturbances  in  secondary  dentition  have  not 
occurred — the  natural  occlusion  of  the  teeth  is  normal,  while  their  sizes  and  rela- 
tive positions  in  the  White  Race  are  that  which  we  have  come  to  recognize  as 
harmonious  with  the  physiognomies  in  which  they  are  placed,  so  that  we  have 
always  before  us  a  fairly  perfect  type  of  normal  occlusion  and  esthetic  dento- 
facial  relations.  Fourth :  It  being  true  that  the  relative  mesio-distal  positions  of 
the  buccal  teeth  are  dependent  upon  those  of  the  first  permanent  molars,  in  con- 
nection with  the  fact  that  the  first  permanent  molars  are  often  subjected  to  early 
influences — such  as  the  premature  loss  of  deciduous  teeth,  etc. — which  causes  them 
to  shift  their  otherwise  normal  positions  in  the  arch,  we  are  led  at  once  to  the  im- 
portance of  preserving  or  establishing  early,  the  normality  of  these  natural  piers 
to  the  future  arches,  in  order  that  normal  occlusion,  natural  esthetic  facial  rela- 
tions, and  permanency  of  retention,  be  attained  in  correction  of  malocclusions. 

But  it  should  be  remembered  that  this  is  but  one  of  the  basic  principles  in  ortho- 
dontia, and  that  it  refers  only  to  that  important  numerous  class  of  irregularities 
in  which  the  natural  or  inherited  disto-mesial  relation  of  the  buccal  teeth  are — or 
were  intended  to  be  in  the  individual — in  harmony  with  all  dependent  physical 


CHAPTER   XI.    PRINCIPLES  OF  OCCLUSION  81 

structures,  and  that  correction  with  the  proper  maintenance  or  attainment  of  a 
normal  occlusion  without  the  loss  of  permanent  teeth  is  indispensable  to  normal 
dento-facial  relations. 

This  covers  so  large  a  class  of  irregularities  that  are  met  with  in  practice,  and 
for  which  the  proper  correction  of  occlusion  without  extraction  is  the  only  true 
treatment,  that  many  in  following  its  teachings  with  happy  results  have  unfor- 
ttmately  been  led  to  believe  in  its  unlimited  applicability. 

One  of  the  greatest  errors  in  this  teaching  is  that  whatever  the  irregularity 
or  facial  deformity,  the  main  and  indispensable  object  in  the  practice  of  orthodon- 
tia is  to  place  the  dentures  in  normal  occlusion.  Today  a  very  large  proportion  of 
orthodontists  who  are  striving  for  the  highest  attainments  in  their  specialty,  have 
learned  by  experience  the  dangers  of  this  arbitrary  and  autocratic  teaching  and 
are  endeavoring  to  treat  their  patients  according  to  facial  as  well  as  occlusal  de- 
mands. The  only  danger  in  this  return  swing  of  the  pendulum  of  progress  is  that 
it  will  too  often  be  permitted  to  swing  beyond  the  true  equilibrium  of  rational 
practice  by  those  who  will  not  take  the  time  to  acquire  the  scientific  principles  of 
diagnosis,  and  thus  again  lead  to  the  inexcusable  extraction  of  teeth  whose  presence 
in  the  arches  are  indispensable  to  the  attainment  of  perfect  results. 

The  perfect  type  of  normal  occlusion  is  beautifully  illustrated  in  Dr.  Cryer's 
collection  of  skulls,  shown  in  Chapter  X.  Attention  is  especially  called  to  that 
shown  in  Fig.  20,  because  it  is  one  which  has  been  frequently  selected  to  represent 
a  normal  occlusion.  It  is  probably  from  a  negro  skull;  and  while  looking  at  it, 
one  can  readily  see — in  the  mind's  eye — the  characteristic  protruding  lips  and  re- 
ceding chin  effect.  Should  the  same  character  of  occlusion,  with  protruding  rela- 
tions of  the  teeth  to  the  jaws,  occur  in  an  Anglo-Saxon  type — as  it  certainly  does 
at  times,  even  to  a  greater  extent — it  would  produce  a  facial  effect  that  could  not 
be  diagnosed  otherwise  than  a  bimaxillary  protrusion,  demanding  extraction. 

In  the  Dental  Cosmos  for  February,  1905,  Dr.  Cryer,  in  speaking  of  this  same 
specimen,  says:  "It  is  certainly  normal  for  that  particular  negro,  but  it  wovild  be 
just  as  reasonable  to  give  the  occlusion  of  a  horse  or  a  dog  and  state  they  are  normal. 
The  point  is  this,  modem  orthodontists  show  upon  the  screen  a  profile  portrait  of 
an  Apollo  Belvedere,  as  an  illustration  of  manly  beauty,  and  then  follow  it  with 
Fig.  20 — the  skull  of  a  prognathous  negro^ — as  an  illustration  of  normal  occlusion." 

In  regard  to  this  phase  of  the  subject,  glance  again  at  the  two  faces  before 
and  after  treatment  reported  in  Dr.  Cryer's  chapter,  and  shown  here  under  Fig. 
27.  The  beginning  face  on  the  left  had  all  the  characteristics  of  an  excessive  bimax- 
illary protrusion.  The  dentures,  as  Dr.  Cryer  has  since  stated  to  the  author,  were 
in  normal  occlusion.  This  case  was  corrected,  as  shown  in  the  face  on  the  right, 
by  the  surgical  removal  of  the  front  teeth  and  alveolar  processes,  and  the  insertion 
of  artificial  dentures  to  restore  the  facial  outlines.  The  face  on  the  left  presents  the 
expression  of  a  degenerate,  despite  a  iwruial  occlusion  of  the  teeth,  while  that  on  the 
right  is  now  characterized  by  the  highest  type  of  intellectuality.     We  can  well 


82 


PART   III.     BASIC   PRIXCIPI.ES  O/-'    PRACTICE 


imagine  that  the  lower  jaw  of  this  patient,  if  dissected  at  the  beginning  of  the  opera- 
tion, would  look  like  Fig.  22,  Chapter  X,  and  that  the  upper  denture  would  be 
similarly  protruded. 

In  pursuance  of  this  phase  of  the  subject,  turn  again  to  the  text  matter  and 
illustrations  of  Bimaxillary  Protrusions,  Division  2,  Class  I,  Chapter  XXIX,  and 
then  ask  yourself:  if  the  hackneyed  and  oft-repeated  teaching  is  of  any  scientific 
value,  which  avers  in  various  forms  that  "a  full  complement  of  teeth  is  necessary 

Fig.  27. 


to  establish  the  most  pleasing  harmony  of  the  facial  outline;"  or  that  "normal  oc- 
clusion is  incompatible  with  any  degree  of  irregvilarity;"  or  that  "normal  occlusion 
and  normal  facial  outlines  are  inseparable."  * 

Throughovit  this  work  the  avithor  has  endeavored  to  teach  that  decided  dis- 
harmony of  facial  otitlines  frequently  exists  with  the  general  disto-mesial  relations 
of  the  dentures  in  normal  occlusion.  This  can  be  verified  to  the  satisfaction  of  any 
inquiring  mind  by  an  observation  of  the  people  to  be  found  everywhere  about 
us.  The  teeth  may  not  be  irregular  in  their  relations  to  each  other;  but  what  is 
malocclusion  broadly  and  truly  speaking,  if  it  is  not  malposition  of  the  teeth  in  re- 
lation to  the  facially  esthetic,  as  well  as  the  anatomic,  and  expressed  by  a  dental 
marring  or  deforming  of  that  perfect  type  which,  from  the  birth  of  classic  art,  has 
appealed  to  the  esthetic  senses? 

In  the  author's  opinion,  the  statement  is  irrefragable  that  all  of  that  large  class 
of  cases  whose  teeth  are  in  normal  occlusion,  but  with  overlying  facial  contours, 
protruded  or  retruded,  to  a  deforming  extent,  should  be  regarded  as  malocclusions, 
demanding  correction,  according  to  our  present  nonienclature,  if  the  science  of 
Dental  Orthopedia  means  anything  beyond  the  mere  correction  of  irregularities  of 
the  teeth  for  mastication  alone. 

*Angle  and  Pullen,  International  Dental  Journal,  October,  19D3,  and  Iten's  of  Interest,  July,  1914. 


CHAPTER   XII 

THE   QUESTION   OF   EXTRACTION    IN    ITS    RELATION   TO   CAUSES, 
DIAGNOSIS,   AND  TREATMENT 

Injudicious,  and  judicious  or  rational  extraction  of  teeth,  as  a  preliminary 
step  to  orthodontic  operations  depends  entirely  upon  causes  and  dento-facial  diag- 
nosis. Therefore,  the  discussion  of  this  branch  of  dental  orthopedia  naturally 
follows  that  of  principles  of  etiology,  and  being  interwoven  with  that  most  impor- 
tant of  all  branches,  diagnosis,  it  will  serve  to  lay  a  foundation  for  the  practical 
treatment  of  all  orthodontic  cases  in  which  the  question  of  extraction  of  permanent 
teeth  should  arise.  Moreover,  this  chapter  and  a  principal  part  of  the  teaching 
throughout  this  v/ork,  is  intended  to  prevent  uncalled-for  and  needless  extraction 
of  teeth  quite  as  much  as  it  is  to  teach  and  fully  define  those  characters  which  at 
times  demand  extraction. 

In  a  paper  read  before  the  National  Dental  Association  of  the  United  States, 
in  1911,  the  author  showed  from  the  statistics  of  his  own  practice  that  in  all  the 
cases  which  presented  for  treatment,  there  was  only  about  one  case  in  twelve  to 
fifteen  in  which  the  question  of  extraction  should  ever  arise.  Inasmuch  as  there 
are  so  comparatively  few  cases  which  do  demand  extraction,  and  for  which  it  is 
quite  as  mvich  malpractice  to  avoid  extraction  as  it  would  be  to  extract  teeth  when 
not  demanded,  it  is  doubly  important  for  us  to  know  exactly  the  character  of  those 
cases,  and  the  kind  of  diagnosis  by  which  they  are  determined. 

Rules  of  Extraction 

If  the  author  were  to  lay  down  rules  relative  to  the  extraction  of  teeth,  he 
would  say :  (1 )  Never  extract  teeth  for  the  purpose  of  making  the  operation  of 
correction  easier,  for  whatever  the  malocclusion,  the  teeth  can  always — or  with 
very  few  exceptions — be  placed  in  arch  alignment  and  in  normal  occlusion,  and  in  a 
very  large  majority  of  all  cases,  they  are  needed  in  the  arches,  not  only  to  perfect 
occlusion,  but  to  aid  in  beautifying  the  facial  outlines.  Therefore,  so  far  as  the 
relations  of  the  teeth  to  each  other  are  concerned,  no  dental  malposition  should  be 
regarded  as  a  basis  for  extraction. 

(2)  Teeth  should  never  be  extracted  in  orthodontia,  except  in  cases  of  excessive 
protrusion,  producing  decided  facial  deformities,  or  at  least  marked  dento-facial 
imperfections — and  not  even  then,  especially  in  young  children,  unless  there 
is  every  indication  of  an  inherent  protrusion  that  will  ultimately  mar  the  beauty  of 
the  face  for  life.  In  nearly  all  locally  caused  malocclusions  in  immature  arches, 
the  final  development  of  the  jaws  and  general  growth  enlargement  of  the  features 

83 


84  PART   III.     BASIC  PRINCIPLES  OF  PRACTICE 

demand  all  of  the  teeth  and  their  sustaining  alveolar  arehes  to  harmonize  the  facial 
relations.  Therefore,  in  every  case  in  which  dento-facial  protrusions  can  be  correct- 
ed without  extraction,  we  should  strive  to  produce  a  normal  occlusion,  not  only  for 
the  sake  of  its  more  perfect  masticating  character,  but  because  of  its  normal  de- 
veloping influences  upon  associate  bones. 

In  former  days  when  the  science  of  orthodontia  was  in  its  infancy,  and  the 
wonderful  yielding  and  responsive  property  of  the  alveolar  processes  and  surround- 
ing tissues  was  not  generally  known,  dentists  indulged  quite  freely  in  the  extraction 
of  teeth  in  all  cases  of  pronounced  malalignments,  and  in  disto-mesial  malocclusions, 
with  little  thought  of  the  true  possibilities  of  treatment,  or  the  demands  which  are 
now  determined  by  dento-facial  diagnosis.  Unfortunately,  this  practice  prevailed 
to  a  considerable  extent  until  Dr.  Edward  H.  Angle  proclaimed  to  the  world  that 
no  teeth  should  ever  be  extracted  in  the  correction  of  malocclusion. 

In  this  remarkable  paper  read  before  the  New  York  State  Dental  Society  in 
1903,  he  said:  "  Extraction  is  wrong.  The  full  complement  of  teeth  is  necessary  to 
the  best  results,  and  each  tooth  should  be  made  to  assume  its  correct  relations  with 
its  fellows.  I  shall  try  to  impress  you"  he  said  "from  the  orthodontist's  standpoint 
with  the  full  value  of  each  individual  tooth  and  with  the  absolute  necessity  of 
preserving  the  full  complement  of  teeth  or  its  equivalent  in  every  case.  I  shall 
try  to  bring  conclusive  evidence  that  the  sacrifice  of  teeth  for  either  the  intended 
prevention  or  correction  of  malocclusion  is  not  only  wrong  practice  and  fallacious 
teaching,  but  most  baneful  in  its  results.  I  shall  further  try  to  show  that  the  full 
complement  of  teeth  is  necessary  to  establish  the  most  pleasing  harmony  of  the 
facial  lines." 

No  one  can  say  that  a  radical  statement  of  this  kind  from  a  man  of  such  emi- 
nence, did  not  do  more  good  in  stopping  the  general  ruthless  extraction  of  teeth 
than  any  half-way  measures,  even  though  untrue  and  not  according  to  the  rational 
teaching  which  is  practiced  by  advanced  orthodontists  of  today. 

Injudicious  Extraction  of  Permanent  Teeth 

One  of  the  most  frequent  errors  in  the  extraction  of  teeth  for  the  correction  of 
malocclusion  has  arisen  in  that  most  common  of  all  irregularities,  maleruption 
of  the  upper  cuspids.  Without  regard  to  the  demands  of  facial  diagnosis,  dentists 
seeing  those  large  cuspids  protruding  through  the  gums  above  their  proper  places 
and  often  with  no  room  for  their  eruption  between  the  laterals  and  first  pre- 
molars, have  imagined  that  their  correction  is  impossible  without  extraction. 
Fig.  28  is  a  fair  sample  of  many  cases.  It  will  be  seen  vipon  the  left  side  of  the 
beginning  dental  models,  that  the  space  for  the  cuspid  was  completely  closed; 
and  notwithstanding  the  very  crowded  condition  of  the  dental  arch,  it  was  evident 
at  the  start,  from  the  undeveloped  facial  area,  that  the  adult  physiognomy  would 
require  all  of  the  teeth  in  the  arches  for  the  development  of  perfect  dento-facial 
outlines  and  beauty. 


CHAPTER   XII.     THE  QUESTION  OF   EXTRACTION 


85 


Fig.  28. 


This  is  well  shown  in  the  photo-print  of  the  face,  which  was  made  from  a  photo- 
graph of  this  patient  taken  several  years  after  treatment.    One  who  would  mar  the 

beauty  of  such  a  face  by  extracting  teeth  to 
aid  in  the  operation  for  correction,  would 
not  deserve  the  title  of  orthodontist. 

The  author  once  listened  to  a  paper  by 
a  dentist  who  claimed  to  be  an  authority 
upon  the  subject  of  regulating  teeth,  and 
who  after  throwing  upon  the  screen  pic- 
tures made  from  dental  models  of  this 
character  of  malocclusion,  said  in  effect: 

"These  cases  are  usually  corrected  by 
extracting  the  first  premolars,  but  some- 
times we  are  obliged  to  extract  the  cus- 
pids;" this  really  tells  the  whole  story. 
There  certainly  are  many  cases  of  mal- 
eruption  of  the  cuspids  in  which  the  ex- 
traction of  the  premolars  is  demanded,  as 
explained  under  the  head  of  judicious  ex- 
traction, but  never  the  extraction  of  cus- 
pids, for  the  reason  that  the  upper  cuspids, 
more  than  any  other  teeth,  serve  to  give 
character  and  esthetic  contour  to  the  fea- 
tures, because  their  large  long  roots  form 
and  sustain  the  canine  eminence  of  the 
maxillae,  and  this  in  turn  prevents  an 
unesthetic  retrusion  of  the  facial  lines  over 
the  area  which  supports  the  wings  of  the 
nose,  and  naso-labial  lines.  This  is  well 
illustrated  under  Practical  Treatment  of  Class  I.  Youths  whose  permanent  upper 
cuspids  have  been  extracted,  or  are  lingually  impacted,  have  a  mature  expression 
far  in  advance  of  their  years,  because  as  people  grow  older,  the  naso-labial 
lines  deepen.  This  is  one  of  the  common  facial  characteristics  of  advancing  years, 
and  one  which  is  greatly  increased  with  edentulous  mouths.  One  of  the  greatest 
difficulties  in  attempts  to  restore  the  original  facial  expression  with  artificial 
dentures,  is  the  impossibility  of  extending  the  rim  of  the  plate  high  enough  t©  re- 
store the  normal  contour  of  the  canine  eminences,  which  in  consequence  leaves  a 
more  or  less  deepened  depression  at  the  wings  of  the  nose. 

Some  years  ago  a  prominent  Chicago  dentist  called  at  the  office  of  the  author 
and  said:  "Doctor,  when  you  have  cuspids  that  are  erupting  through  the  gums 
above,  and  with  no  spaces  between  the  laterals  and  first  premolars,  you  have  to 
extract  teeth  to  get  them  into  the  arch,  do  you  not?"    In  reply,  he  was  shown 


86 


PART   III.     BASIC   I'RIXCIPLES  Ol<    PRACTICE 


*"■  "  the  plaster  models  of  a  number  of  cases  which  proved 

tliat  however  irregular  the  teeth,  however  bunched,  mal- 
aligned,  or  malposed,  they  could  always  be  placed  in 
their  respective  places  in  the  arches  and  in  normal  occlu- 
sion, and  therefore,  so  far  as  the  relations  of  the  teeth 
to  each  other  are  concerned,  no  dental  malposition 
should  be  regarded  as  a  basis  for  extraction. 

When  these  truths  dawned  upon  his  mind  he  said: 
"I  believe  I  have  made  a  very  great  error,  doubly  so, 
because  it  is  in  the  family  of  some  very  dear  friends  of 
mine.  Wishing  to  do  the  very  best  for  their  little  daugh- 
ter whose  tipper  cuspids  were  erupting  in  that  way,  I 
extracted  the  first  premolars,  and  now  at  about  fifteen 
years  of  age,  I  find  that  all  the  upper  front  teeth  are 
biting  back  of  the  lowers,  with  quite  a  depression  of  the 
upper  lip,  which  gives  her  the  appearance  of  a  pro- 
truding lower  jaw." 

Fig.  29  shows  on  the  left  the  position  of  her  teeth 
when  she  was  brought  to  the  author;  and,  on  the  right, 
is  shown  the  position  of  her  teeth  after  correction,  by  a 
bodily  labial  movement  of  the  upper  front  teeth,  opening  spaces  for  the  insertion 

of  artificial  premolars. 

Another  case  similar  to  the  above,  sent  to 
the  author  from  Ohio,  is  shown  in  Fig.  30. 
In  the  letter  of  introduction  from  the  dentist 
who  referred  the  case,  he  said:  "I  have 
extracted  the  first  premolars  knowing  that 
you  would  find  it  necessary."  Anyone  can 
see  by  the  facial  lines  alone,  to  say  nothing 
of  the  fact  that  the  upper  front  teeth  close 
back  of  the  lowers,  that  it  was  the  very  height 
of  orthodontic  malpractice  to  extract  teeth 
from  the  upper  arch.  The  only  excuse  for 
extracting  sound  permanent  teeth — an  axiom 
which  cannot  be  too  often  repeated — is  the 
impossibility  of  otherwise  correcting  the  mal- 
occlusion without  leaving  a  facial  protrusion. 
To  remove  one  or  mere  teeth  from  immature 
arches  for  the  purpose  of  more  easily  correct- 
ing an  irregularity  that  has  arisen  wholly 
from  local  causes,  will  inevitably  produce  its  eft'ect.  And  the  eftect  upon  arches 
that  would  otherwise  be  ultimately  correct  in  size  and  occlusion  is  to  abnormally 


Fig.  :i(). 


CHAPTER   XII.     THE  QUESTION  OF  EXTRACTION  87 

contract  them  and  to  force  the  occluding  teeth  of  the  opposing  jaw  into  malaHgn- 
ments,  besides  producing  more  or  less  imperfections  in  esthetic  facial  contours. 
And  under  certain  circumstances  as  instanced  by  the  two  cases  illustrated,  it  may 
result  in  an  actual  facial  deformity,  and,  too,  when  the  operation  is  performed  by 
men  who  are  supposed  to  know  better. 

Besides  the  thousands  of  occlusal  malrelations  that  have  been  caused  by  the 
needless  and  even  criminal  extraction  of  permanent  teeth,  there  are  numberless 
dento-facial  imperfections  and  deformities  that  have  gone  through  life  from  this 
cause  alone.  It  has  frequently  been  a  matter  of  great  surprise  to  see  the  results  of 
poor  judgment  shown  by  dentists,  even  of  advanced  standing,  in  extracting  de- 
ciduous and  permanent  teeth;  and  when  one  considers  the  thousands  of  young 
dentists  of  less  experience  who  are  let  loose  upon  trusting  communities,  it  is  not 
strange  that  there  arise  so  many  examples  of  criminal  malpractice  along  this  line, 
especially  in  the  extraction  of  permanent  teeth  from  crowded  arches  in  which  all 
the  teeth  are  necessary  to  perfect  occlusion  and  dento-facial  relations.  Many 
seem  to  be  wholly  ignorant  of  the  quality,  possibilities  of  movement,  and  function 
of  the  alveolar  process,  which  is  always  susceptible  of  any  required  degree  of  arch 
enlargement  to  accommodate  the  teeth,  however  crowded  or  malaligned. 

Judicious  or  Rational  Extraction  of  Permanent  Teeth 

While  it  is  true  that  too  much  cannot  be  said  in  regard  to  the  needless  extrac- 
tion of  teeth,  the  principle  of  non-extraction  of  teeth,  nevertheless,  has  its  limita- 
tions from  a  true  orthodontic  standpoint.  The  question  may  well  be  asked:  Do 
the  tmtold  evidences  of  this  character  of  malpractice  prove  that  extraction  should 
never  be  resorted  to  under  any  condition?  In  other  words,  does  this  prove  "that 
extraction  is  wrong  and  that  the  full  complement  of  teeth  or  their  equivalent  is 
necessary  to  the  best  results  in  every  case?"  Most  certainly  not.  It  simply  proves 
that  the  injudicious  and  needless  extraction  of  teeth  when  not  demanded  for  the 
correction  of  dento-facial  protrusion  should  be  condemned  in  the  strongest  possible 
terms.  The  collection  and  portrayal  of  disasters  in  railroad  travel  and  in  the  vise 
of  anesthetics  would  be  quite  as  legitimate  to  prove  that  humanity  should  desist 
from  the  employment  of  these  benefits  as  that  such  evidences  should  be  presented 
as  frequently  have  been  to  prove  that  extraction  is  never  demanded  in  the  coiTcction 
of  dento-facial  deformities. 

It  has  been  frequently  asserted  or  implied  that  a  normal  occlusion — which 
means:  "without  the  loss  of  a  single  tooth" — is  the  only  occlusion  which  presents 
sufficient  opporttmity  for  healthful  mastication  of  food  and  perfect  retention  of 
teeth  in  corrected  positions.  This  is  not  true,  because  the  ultimate  masticating 
closure  of  many  quite  irregular  dentures,  and  especially  those  cases  of  full  malin- 
terdigitation  of  buccal  cusps  supply  every  need  for  perfect  mastication.  And  be- 
cause the  teeth  have  assumed  that  position  through  intrinsic  local  forces,  their 
retention  is  assured,  unless  artificially  changed.     Therefore,  this  theory  cannot  be 


88  PART   III.     BASIC   I'RIXCII'I.ES  OF   PRACTICE 

used  as  an  argument  for  non-extraction  any  more  truthfully  than  the  statement  that 
a  normal  occlusion  is  the  only  occlusion  that  is  compatible  with  esthetic  facial 
outlines.  In  fact,  it  will  be  found  that  an  extensive  disto-mesial  shifting  of  the 
dentures  with  the  intermaxillary  force  to  produce  the  relations  of  a  normal  occlusion 
is  far  more  liable  to  result  in  non-retention  than  are  those  cases  where  premolars 
have  been  extracted  and  the  six  front  teeth  retruded,  with  the  original  disto-mesial 
occlusion  of  masticating  teeth  undisturbed,  or  slightly  shifted  to  correct  lateral 
relations  and  the  more  perfect  interdigitation  of  the  cusps.  Furthermore,  when  the 
first  or  second  premolars  are  extracted,  the  spaces  are  perfectly  closed,  the  inter- 
digitation of  the  cusps  of  the  back  teeth  is  adjusted,  mastication  of  food  and  per- 
manency of  retention  are  assured,  while  the  relations  of  the  dentures  should  be  such 
that  they  give  no  appearance  of  missing  teeth. 

In  Class  I,  the  buccal  teeth  are  disto-mesially  normal  in  occlusion,  and  though 
presenting  a  great  variety  of  irregularities  from  the  simplest  to  the  most  complex, 
when  they  are  corrected  for  youthful  patients,  and  the  dentures  are  placed  in  nor- 
mal occlusion  with  proper  arch  width,  usually  the  most  perfect  results  possible  are 
accomplished.  But,  if  after  such  an  operation  it  is  found  that  they  produce  a  facial 
protrusion,  it  must  be  a  protrusion  of  both  dentures,  protruding  the  upper  and 
lower  lips.  This,  when  characterized  by  a  receding  chin  effect,  may  have  all  the 
appearances  of  a  typical  bimaxillary  protrusion.  If  any  teeth  are  extracted  to 
correct  this  condition  it  must  be  from  both  upper  and  lower  dentures,  and  if  the 
protrusion  is  bilateral,  as  it  is  very  liable  to  be,  it  would  mean  the  extraction  of  right 
and  left  upper  and  right  and  left  lower  teeth. 

Then  the  very  grave  question  arises:  Does  the  facial  imperfection  warrant 
the  extraction  of  four  sound  teeth  from  youthful  dentures  which  are  now  in  per- 
fect normal  occlusion?  If  the  protrusion  is  not  very  pronounced  and  cannot 
be  traced  to  one  or  the  other  parent  as  a  family  type,  and  the  patient  is  under 
12  years  of  age,  one  should  never  think  of  extraction  until  he  has  seen  what 
the  developing  forces  of  nature  will  accomplish.  If  at  14  or  15  years  of  age  it 
has  partially  disappeared,  there  is  very  good  reason  to  believe  it  will  wholly 
disappear  at  18. 

It  was  shown  in  Chapter  V,  how  through  premature  loss  of  the  deciduous  teeth, 
protrusions  both  unimaxillary  and  bimaxillary  may  arise.  Again,  it  was  shown 
under  the  last  heading  of  that  chapter  that  during  the  years  of  rapid  secondary 
dentition  there  is  nearly  always  a  general  protrusion  of  the  lips  and  all  that  facial 
area  supported  by  the  large  erupting  teeth  and  alveolar  processes,  which  is  accepted 
by  us  with  no  anxiety  because  it  is  the  common  childhood  facial  characteristic. 
Moreover,  the  forces  of  heredity  which  characterize  the  framework  of  physiog- 
nomies, as  in  other  parts  of  the  body,  are  not  often  sufficiently  pronounced  before 
the  beginning  of  adolescence,  or  of  puberty,  for  us  to  determine  definitely  what  the 
final  facial  characteristics  will  be.  Therefore,  it  will  be  seen  by  these  foundation 
principles  of  diagnosis  that  great  caution  and  judgment  should  be  exercised  before 


CHAPTER   XII.     THE  QUESTION  OF  EXTRACTION  89 

attempting  early  capital  orthodontic  operations  which  later  development  may  prove 
to  be  decidedly  wrong. 

On  the  other  hand,  if  after  correcting  the  alignment  and  occlusion  of  a  Class 
I  case,  it  is  found  at  fourteen  years  of  age,  or  older  that  the  physiognomy  bears 
all  the  characteristics  of  a  developing  pronounced  bimaxillary  protrusion,  or  if  a 
new  case  presents  with  that  facial  characteristic  determined  by  protruding  lips 
and  receding  chin  effect,  it  is  then  up  to  the  patient  or  the  parents  to  say  whether 
they  are  willing  to  undergo  the  required  operation  for  the  purpose  of  beautifying 
the  face — an  operation  that  is  not  guesswork  if  properly  performed,  but  one  which 
is  just  as  sure  in  its  resvilts  as  any  other  operation  of  dento-facial  nrthopcdia. 

In  Chapter  XXIX,  under  practical  treatment  of  Bimaxillary  Malocclusion, 
Division  2,  Class  I,  there  is  described  and  illustrated  under  Fig.  164  a  very  in- 
teresting case  which  is  quite  apropos  to  the  question  of  extraction.  It  shows  how 
an  endeavor  was  made  to  correct  an  apparently  simple  irregularity  in  a  Class  I 
case  of  a  miss  fourteen  years  of  age,  by  placing  the  dentures  in  normal  occlusion, 
which  resulted  in  a  prominence  of  the  mouth,  but  one  which  it  was  hoped  that 
adolescent  growth  would  harmonize  in  the  general  development  of  the  surrounding 
bones  of  the  physiognomy.  Instead  of  this,  however,  at  nearly  seventeen  years  of 
age,  the  unpleasant  protrusion  seemed  more  pronounced,  if  anything,  than  when 
the  case  was  first  corrected.  This  was  doubtless  due  to  the  fact  that  the  maturing 
development  of  the  features  had  assumed  the  delicate  type  of  the  mother,  and 
this  brought  out  in  stronger  relief  the  labial  disharmony,  which  is  well  shown  by  the 
facial  cast  which  was  made  at  that  time.  The  four  first  premolars  were  then 
extracted,  and  this  enabled  a  comparatively  easy  retruding  movement  of  the  twelve 
labial  teeth,  and  resulted  in  a  beautiful  harmonizing  effect  of  the  entire  dento-facial 
outlines,  as  shown  by  the  final  facial  cast,  and  a  photograph  taken  two  years  later. 

Like  all  other  cases  that  are  properly  treated  in  this  way,  the  remaining  teeth 
were  in  normal  occlusal  relations,  affording  an  opportunity  for  the  mastication 
of  food  fully  equal  to  any  normal  occlusion. 

In  a  Class  II  case,  if  after  correcting  it  by  shifting  the  dentures  to  a  normal 
occlusion,  it  is  found  at  fourteen  or  fifteen  years  of  age  that  the  lips  are  unpleasantly 
protruded,  marring  the  facial  outlines  that  would  otherwise  be  perfect,  it  will  be 
because  the  case  originally  was  not  a  lower  retriision,  but  cm  upper  protrusion  which 
demanded  the  extraction  of  the  first  upper  premolars.  Dr.  Cryer  has  said  that 
he  has  seen  a  number  of  cases  with  protruding  mouths  right  from  the  hands  of 
orthodontists  who  doubtless  believed  it  was  wrong  to  extract  in  the  correction  of 
any  case. 

Should  such  a  contingency  arise  in  practice,  with  a  desire  or  willingness  on  the 
part  of  the  patient  to  have  the  protruded  facial  outlines  corrected  by  a  second 
operation,  the  following  would  be  the  proper  treatment:  If  the  protrusion  is  not 
excessive,  extract  the  first  upper  premolars  and  then,  with  stationary  anchorage 
on  the  upper  buccal  teeth,  retrude  the  lower  denture  with  the  intermaxillary  force 


90  PART   III.     BASIC   PRIXCIPLKS  OF   PRACTICE 

to  its  original  normal  position.  In  connection  with  the  movement — from  rootwise 
extensions  on  the  anchorages — retrude  the  six  upper  front  teeth  to  close  the  spaces 
of  the  extracted  premolars.  If,  however,  the  protrusion  is  quite  decidedly  pro- 
nounced, with  a  receding  chin  effect,  extract  the  four  first  premolars.  Proceed  in 
these  operations  as  fully  described  under  "Practical  Treatment  of  Bimaxillary 
Protrusions." 

The  large  majority  of  the  most  advanced  orthodontists  today  are  practicing 
the  judicious  extraction  of  teeth  according  to  the  teaching  which  is  outlined  in  this 
work.  But  unfortunately  there  are  a  number  of  prominent  orthodontists  who  are 
still  practicing  the  extreme  autocratic  teaching  of  Dr.  Angle,  with  results  no  doubt, 
in  many  cases  that  should  not  satisfy  anyone  whose  aim  is  the  attainment  of  the 
highest  plane  in  modern  orthodontia. 

As  an  illustration  of  this :  A  family  of  very  moderate  means  consulted  an  Angle 
orthodontist  of  high  reputation  in  regard  to  the  correction  of  their  son's  teeth, 
who  at  that  time  was  twelve  years  of  age.  The  prominent  feature  of  the  case  was 
a  deforming  labial  maleruption  of  the  upper  cuspids,  which  was  locally  due  to  the 
premature  extraction  of  the  deciduous  cuspids  in  a  mouth  which  distinctly  indicated 
an  inherited  upper  protrusion,  shown  by  the  mesial  malocclusion  of  the  upper 
buccal  teeth  in  connection  with  a  normally  posed  chin  and  lower  lip,  and  proven  by 
a  similar  occlusion  in  one  of  the  parents.  The  straining  force  of  the  upper  lip  had 
caused  the  incisors  to  drift  back  and  shut  the  spaces  for  the  normal  eruptioa  of  the 
unusually  large  permanent  cuspids.  One  of  the  complications  of  the  case  was  the 
decayed  and  broken  down  condition  of  the  right  lower  first  molar  in  which  the  pulp 
had  long  since  died,  and  had  given  trouble  from  abscessed  condition. 

The  treatment  outlined  by  the  said  orthodontist  was  to  place  the  dentures  in 
normal  occlusion  and  restore  the  molar  with  a  crown;  this  is  the  same  principle  of 
treatment  that  has  been  strictly  followed  in  the  past  by  the  Angle  school  of  ortho- 
dontia, and  is  unfortunately  still  followed  by  many  who  earnestly  believe  it  to  be 
the  trvie  principle  in  the  correction  of  all  malocclusions. 

The  case  fell  into  the  author's  hands  because  of  the — to  them — prohibitive 
fee,  which  led  the  father  to  inquire  if  it  could  be  corrected  at  the  college.  It  is 
needless  to  say  that  the  extraction  of  the  two  upper  first  premolars  was  ordered; 
this  gave  very  little  more  room  than  necessary  for  the  eruption  and  alignment  of 
the  cuspids.  The  diseased  lower  molar  was  also  extracted,  as  no  capable  dentist 
in  these  days  would  attempt  to  restore  it. 

With  the  exception  of  appliances  for  the  bodily  mesial  movement  of  the  second 
molar  to  close  the  space  of  the  extracted  first  molar,  the  case  would  have  corrected 
itself  if  given  time  tmder  ordinary  circtimstances.  It  was  hastened  with  an  upper 
apparatus  having  a  resilient  bow  for  the  cvispid  movements,  and  the  intermaxillary 
force  for  adjusting  the  occlusion  and  as  an  aid  in  the  mesial  movement  of  the  molar. 

Fig.  31  shows  the  facial  and  dental  models  of  the  case  at  the  beginning  and 
when  the  operation  was  completed.     Fig.  32  shows  occlusal  aspect  of  the  dentures. 


CHAPTER   XII.     THE  QUESTION   OF  EXTRACTION 


91 


The  whole  subject  of  extraction  of  permanent  teeth  in  the  practice  of  dento- 
facial  orthopedia  resolves  itself  into  the  question  of  its  importance  to  the  patient. 
Is  it  important  to  correct  facial  imperfections  and  deformities  caused  by  protruding 


Fig.  31. 


1^  ^^  ^Q^ 


Fig.  32. 


teeth  which  cannot  be  accomplished  without  extraction,  and  when  by  the  sacrifice 
of  certain  teeth  a  most  satisfactory  result  of  the  operation  in  this  regard  and  also 
in  permanency  of  retention  is  assured? 

The  subject  is  of  so  much  importance  in  dento-facial  orthopedia,  it  will  be  con- 
tmued  in  other  chapters  in  connection  with  allied  principles  and  practice,  so  that 
the  student  will  have  an  opportunity  to  study  it  from  many  viewpoints. 


PART   IV 


Technic  Principles  of  Practice 


TECHNIC  PRINCIPLES  OF  PRACTICE 


CHAPTER  XIII 

PRINCIPLES    OF   MECHANICS    IN   THE   MOVEMENT   OF   TEETH 

In  the  contemplation  of  applying  force  to  a  tooth  for  its  niovement,  every 
condition  should  be  considered:  (1)  its  situation  in  relation  to  the  arch  and  ad- 
joining teeth;  (2)  the  number,  probable  length,  shape,  and  inclination  of  its  roots; 
(3)  the  probable  yielding  quality  of  its  alveolar  imbedment  in  relation  to  the  re- 
quired movement;  (4)  the  possibility  of  attaching  appliances  to  the  crown  which 
will  permit  the  proper  application  of  force;  (5)  and  finally,  the  influences  of  occlu- 
sion, dento-facial  relations,  and  the  possibilities  of  retention. 

A  dental  regulating  apparatus — ho-wever  simple  or  complex — is  a  machine 
for  the  application  and  transmission  of  power  which  is  given  to  it  by  the  operator 
in  the  form  of  potential  energy  for  the  movement  and  correction,  primarily,  of 
malposed  teeth;  and  secondarily  for  the  correction  of  all  forms  of  malocclusion 
and  dento-facial  imperfections. 

A  machine  is  a  contrivance,  or  device,  or  a  coml;)ination  of  mechanical  elements 
by  means  of  which  a  force  or  forces  may  be  advantageously  applied.  Every  ma- 
chine, however  complicated,  is  reducible  to  five  elementary  forces,  which  have  been 
named  "the  mechanical  powers,"  i.  e.,  the  lever;  the  wheel  and  pulley;  the  screw; 
the  inclined  plane ;  and  the  wedge.  A  little  thought  will  show  that  the  mechanical 
principle  of  the  wheel  and  axle  isee  Fig.  47  )  is  exactly  that  of  a  lever;  and  that  the 
advantage  derived  from  the  inclined  plane  and  wedge  is  the  same  as  that  of  a  screw. 
Therefore,  the  real  elemental  mechanical  powers  are  the  lever  and  the  screw. 

One  of  the  most  important  factors  of  a  regulating  machine  or  apparatus  is  that 
obtained  from  the  backward  spring  or  elasticity  of  metal,  rubber,  silk,  etc.,  by 
virtue  of  the  quality  of  these  substances  to  regain  their  former  positions  when  their 
molecules  are  forced  out  of  equilibrium.  This  resilient  property  enables  the  storing 
up  of  potential  energy  to  be  slowly  liberated  in  the  form  of  continuous  force — 
a  form  of  force  which  seems  especially  calculated  to  arouse  bone-cell  activities, 
where  the  real  metamorphic  work  in  the  movement  of  teeth  is  carried  on. 

There  is,  however,  a  very  erroneous  impression  prevailing  in  regard  to  the 
action  of  the  so-called  "positive  forces  of  a  screw,"  when  applied  for  the  movements 
of  teeth,  which  grew  out  of  Dr.  Farrar's  statement  that  it  was  in  accord  with  the 
common  physiologic  functional  requirement  of  "work  and  rest."  With  properly 
constructed  appliances  and  properly  conducted  treatments,  a  nut  is  never  turned 

95 


96  PART   IV.     TF.CnXfC   f'Rf XCf Pf.F.S  OF   PRACTICE 

more  than  to  <^ive  a  sli<^^ht  smi}^  fcc'lin,<,^  wiiich  passes  away  in  a  few  moments. 
This  is  accomphshed  by  giving  two  or  three-qvuirter  turns  about  every  third  day. 
The  real  work  in  tlw  rc^iilatio)!  of  ieclh  by  this  movement  is  not  accomplished  when 
llie  nuts  are  turned,  but  it  occurs  only  ilnrini^  titc  lon;j^  iiitervals  of  so-called  "rest." 

The  immediate  action  in  screw  force,  is  to  move  the  roots  shghtly — bodily 
or  otherwise — in  the  direction  of  the  apphed  force,  but  the  surrounding  alveolar 
process  is  not  moved  at  this  time,  because  the  root  never  comes  into  actual  contact 
with  its  bony  socket.  The  highly  elastic  and  more  or  less  thickened  peridental 
membrane  upon  which  the  root  impinges  is  forced  out  of  ecjuilibrium,  and  is  thereby 
stored  witli  the  same  kind  of  potential  energy  as  occurs  from  the  resilient  powers 
of  extraneous  forces.  When  the  force  is  transmitted  through  the  medium  of  a  bow, 
even  though  the  bow  is  apparently  quite  rigid,  it  also  stores  potential  force,  and 
from  both  of  these  sources  the  force  is  slowly  transmitted  to  the  alveolar  process 
where  the  real  work  of  movement  is  carried  on. 

The  intrinsic  action  of  the  spring  cushion  is  exactly  the  same  as  the  extrinsic 
action  of  any  kind  of  the  resilient  forces;  the  only  difference  being  that  in  one  the 
intensity  of  the  force  gradually  diminishes  until  it  comes  to  rest,  but  if  the  treat- 
ment adjustments  are  timed  and  modified  exactly  in  accord  with  tlie  possibilities 
of  work,  it  is  as  continuous  as  any  of  the  continuous  forces.  In  fact,  whenever  teeth 
are  moved  physiologically,  by  whatever  means,  it  is  always  through  a  continuous 
pressure  of  the  crowded  peridental  membrane  upon  the  alveolar  process,  which 
causes  it  to  slowly  move  out  of  the  way,  either  through  the  property  of  resorption, 
or  by  a  more  or  less  bodily  movement  en  masse,  so  that  the  immediate  tissues 
which  are  necessary  for  the  vitality  of  the  teeth  may  return  to  equililjrium. 

Kinds  of  Movement 

The  mechanical  processes  of  correcting  malposed  teeth  may  be  divided  into 
five  Primary  Movements  which,  placed  according  to  their  degree  of  demands,  are: 
Inclination,  Rotating,  Bodily,  Extrusive,  and  Intrusive.  The  movements  which 
are  most  commonly  demanded  are  Compound  Movements  which  are  made  up  of 
two  or  more  of  the  Primary  Movements. 

Inclination  Movement. — Inclination  Movement  in  Orthodontia  is  the  most 
important,  because  it  is  by  far  the  most  common.  It  also  presents  a  far  greater 
variety  of  possibilities  and  demands  in  the  application  of  force. 

In  nearly  all  orthopedic  movements  of  teeth  the  apical  ends  of  the  roots  do 
not  move,  at  least  not  in  the  direction  of  the  applied  power,  unless  the  apparatus  is 
especially  constructed  for  that  purpose,  as  will  be  explained  later  under  the  head  of 
Bodily  Movement.  Therefore,  while  nearly  all  movements  are  produced  by  forcing 
the  occlusal  end  of  the  tooth  along  the  arc  of  a  circle  whose  pivotal  point  is  near  the 
apex  of  the  root,  it  usually  is  eminently  desirable  that  the  movement  be  kept  at  a 
minimum  of  its  inclination  tendency,  in  order  that  the  teeth  when  properly  aligned 
will  stand  in  normal  pose. 


CHAPTER   XI 11.     PRINCIPLES  OF  MECHANICS 


97 


Fig.  33. 


\Micn  a  pull  ur  push  force  is  applied  to  the  crown  of  a  tooth  at  any  point  whose 
line  of  direction  is  at  right  angles  to  its  central  axis,  the  movement  that  takes 
place  will  be  purely  that  of  Inclination,  providing  that  perfect  freedom  of  movement 
is  permitted  at  the  point  of  applied  power. 

When  force  is  applied  in  this  way  to  the  incisal  zone  "a," 
Fig.  33,  of  a  tooth,  far  less  power  is  required  for  its  movement, 
with  a  greater  tendency  toward  inclination,  than  if  applied  at 
the  gingival  zone  "b"  or  at  any  point  further  root-wise.  There 
will  also  be  a  greater  tendency  toward  a  movement  of  the  apical 
zone  in  the  opposite  direction.  By  this  example  it  will  be  seen 
that  a  tooth  imbedded  in  a  yielding  medium  which  forms  its 
socket,  and  subjected  to  force  appliances  attached  to  its  crown 
for  its  movement,  is  practically  a  lever,  responding  approximately  to  the  same  laws 
which  govern  levers  everywhere  under  like  conditions  of  stress. 

Levers 

The  ordinary  mechanical  lever  is  a  rigid  bar,  or  inflexible  rod,  straight  or  bent, 
resting  upon  a  prop  called  a  fulcrum,  and  with  power  and  weight  disposed  at  some 
,,     ., ,  two  other  points. 

Pig.  34.  _^ 

The  different  ways  in  which  the 
three  factors,  power,  weight,  and 
fulcrum,  may  be  disposed  give 
rise  to  three  kinds  of  levers.  See 
Fig.  34. 

In    mechanics    the    important 
factors   of   levers   are   power   and 
weight    and    the    length    of    the 
ower  and  the  weight-;arms. 

Given  three  of  these  factor^, 
the  other  can  always  be  determined  by  the  following  rule  which  applies  to  all  true 
levers :  s 

Law  of  Levers.  Power  and  weight  are  in  the  inverse  ratio  to  their  distance 
from  the  fulcrum. 

The  distance  from  the  fulcrum  at  which  power  and  weight  are  placed  indicates*^, 
the  length  of  the  power  and  weight-arms  respectively.  If  we  wish  to  know,  for 
example,  how  much  power  will  be  required  with  a  6-foot  lever  of  the  "first  kind" 
to  sustain  a  weight  of  25  pounds,  with  the  fulcrum  placed  one  foot  from  the  weight, 
we  have  but  to  state  the  inverse  ratio  as  follows:  Power-arm  (5)  is  to  Weight-arm 
(1)  as  Weight  (25)  is  to  Power  (  X  ),  or 

5:1    ::   25    :  X.     Ans.  5  pounds. 
Again,  how  much  weight  will  5  pounds  of  power  lift  with  a  ()-foot  lever  of  the 
"second  kind,"  witli  the  weight  placed  one  foot  from  the  fulcrum? 


First  Kind 


Pc 


bW 


w 


Second  Kind  pc 


/*^ 


^v 


Third  Kind 


=iF 


\ 


98  PART  IV.     TEClIXfC   I'RIXCIPLES  OF   PRACTICE 

Weight-arm  (1  )  is  t(i  Power-arm  (fi)  as  Power  (5)  is  to  Weight  f  X),  or 
1    :   ()    ::   5    :    X.     Ans.  ;■?()  pounds.     Etc. 

Levers  in  Relation  to  Laterally  Moved  Teeth. — Ap])lied  Mechanics  in  comput- 
ing quantities  deals  only  with  power  and  weight  or  work,  exemplified  in  the  above 
genend  law  of  levers.  Little  is  said  of  the  force  of  reaction,  or  the  force  sustained 
at  the  fulcrum;  whereas,  with  a  tooth  considered  as  a  lever,  the  action  at  fulcrum, 
as  will  be  shown,  is  quite  as  iniportant  for  us  to  consider  as  the  force  which  is  exerted 
at  the  points  known  as  power  and  weight;  and,  moreover,  it  is  important  to  keep 
in  mind  approximately  the  relation  which  tliis  force  bears  to  the  other  factors. 
While  it  is  never  possible  or  necessary  to  calculate  these  quantities  accurately,  still, 
in  order  to  arrive  at  the  rough  estimate  desirable,  a  clear  conception  of  the  mathe- 
matical methods  employed  according  to  the  laws  of  physics,  especially  those  re- 
lating to  levers,  is  very  important.  This  can  easily  be  approximated  with  levers 
when  we  remember  another  law  of  levers,  i.  e. :  Force  exerted  or  sustained  by  the 
middle  factor  of  a  lever  at  equilibrium,  be  it  fulcrum,  weight,  or  power,  is  equal 
to  the  sum  of  the  other  two  factors.  This  law  shows  why  a  lever  of  the  second 
kind  is  always  chosen  where  great  force  is  required  at  the  expense  of  motion. 

Again,  in  the  typical  lever  the  fulcrum  is  always  considered  a  fixed  point,  but 
we  are  aware  there  are  a  number  of  implements  employed  in  mechanics  that  exert 
force  according  to  the  principles  of  levers,  though  in  construction  they  differ  in 
certain  particulars  from  every  one  of  the  three  kinds.  Common  examples  of  this 
are  all  forms  of  the  pulley  and  the  wheel  and  axle  power. 

Fulcrum  and  Weight  Interchangeable. — There  is,  furthermore,  a  not  uncom- 
mon kind  of  lever  in  which  points  of  weight  and  fulcrum,  in  their  activities  upon 
each  other,  are  more  or  less  interchangeable — each  acting  as  a  fulcrum  for  the  other, 
with  varying  stability  and  relative  energy,  governed  by  the  velocity  of  the  moving 
power  and  the  relative  length  of  the  power-arm. 

An  example  of  a  lever  of  this  kind  is  an  oar  of  a  rowboat.  In  proportion  to  the 
velocity  of  the  moving  power  exerted  by  the  rower,  above  the  possibilities  of  the 
water  to  get  out  of  the  way  of  the  blade,  the  oar  becomes  a  lever  of  the  second 
kind  and  the  boat  or  work  moves  forward.  But  if  the  velocity  of  the  moving  power 
is  not  sufficient  to  overcome  the  inertia  of  the  boat,  the  only  work  that  the  oar  or 
lever  can  be  said  to  accomplish  is  the  movement  of  the  yielding  water  in  front  of  the 
blade,  with  fulcrum  at  the  oarlock — or  the  action  of  a  lever  of  the  first  kind.  It 
can  be  seen  in  this  common  example  of  a  lever  of  the  second  kind  that  the  fulcrum, 
or  so-called  point  of  resistance,  is  a  broad  moving  area  of  water.  And  it  would 
be  none  the  less  a  lever  if  its  so-called  point  of  work  was  also  spread  over  a  broadened 
area  upon  the  lever,  both  areas  of  fulcrum  and  weight  moving  and  reacting  upon 
each  other. 

This  combination  of  activities  is  exactly  that  which  is  exemplified  in  the  alveo- 
lus of  a  tooth  when  force  is  applied  in  a  lateral  direction  upon  the  crown.  It  is 
perfectly  illustrated  also  in  the  following  example  of  the  post  lever. 


CHAPTER   XIII.     PRfXCIPLES  OF  MECHANICS 


99 


''"'■  ■^'■'-  Post  Lever. — If  you  should  drive  a  four-foot  post  one-half 

its  length  into  clayey  soil  of  uniform  quality,  and  then  take  hold 
of  the  top  of  the  post  and  move  it  back  and  forth  with  a  view 
of  subsequently  pulling  it  out  of  the  ground,  you  would  be 
working  a  lever  which  combines  the  qualities  of  the  first  and 
second  kinds,  or  one  like  the  oar  in  which  the  so-called  areas 
of  fulcrum  and  weight  act  as  fulcrums  to  the  other.  See 
Fig.  35.  After  pulling  the  post  out  of  the  ground,  if  it  were 
possible  for  you  to  make  a  transverse  section  of  the  soil  for 
the  purpose  of  examining  the  shape  of  the  hole  you  had 
made,  you  would  find  it  somewhat  the  shape  of  an  hour- 
glass ;  the  upper  portion  of  the  opening  being  about  twice  as 
large  as  the  lower.  * 

As  the  post  is  forced  in  one  direction  the  soil  in  front  of 

it,  along  its  upper  sphere  of  action,  will  become  impacted, 

or  thrust  to  one  side,  the  post  thus  acting  as  a  lever  of  the 

second  kind,  with  fulcrum  at  the  lower  end.    At  some  point 

along  its  imbedded  length,  however,  it  will  cease  to  move  in 

the  direction  of  the  applied  power,  because  the  resistance  of  the  soil  in  the  upper 

area  causes  it,  in  turn,  to  act  as  a  fulcrum,  and  the  whole  as  a  lever  of  the  first  kind, 

with  work  or  movement  at  the  lower  end  in  the  opposite  direction. 

The  reason  that  the  upper  area  of  work  is  about  twice  that  of  the  lower  in  the 
above  example,  and  also  the  changed  relations  with  power  applied  at  difterent 
points,  may  be  fovmd  in  an  examination  of  other  examples  which  refer  to  the  rela- 
tion of  the  three  factors  of  levers. 

Levers  of  the  First  Kind. — The  beam  of  balance  scales  is  a  lever  of  the  first 

kind.  The  support  or  central  stand- 
ard is  the  fvilcrum,  with  points  of 
power  and  weight  at  the  end  attach- 
ments for  the  pans.  See  Fig.  36. 
It  can  now  be  seen  at  once  that  when 
the  beam  or  lever  is  at  equilibrium 
the  fulcruni  sustains  the  sum  of 
power  and  weight,  and  this  would 
hold  true  of  any  lever  of  the  first  kind 
at  whatever  intermediate  point  be- 
tween power  and  weight  the  fulcrum 
is  placed.  Therefore,  when  the  ful- 
crum is  exactly  in  the  middle  of  the 
lever  of  the  first  kind,  at  equilibrium, 

*In  mathematical  exactness,  a  post  moved  in  this  way,  with  its  imbedded  portion  completely  surrounded  with 
a  homogeneous  resisting  medium,  the  depth  of  the  upper  V-shaped  opening  would  be  somewhat  less  than  two- 
thirds  the  entire  depth  of  the  hole. 


lUO 


PART  IV.     TECIIMC  J'RIXCIPLliS  OF   PRACTICE 


(J= 


Fig.  37 


w 


15 


=0 


15 


Fig.  3S. 


it  receives  twice  as  much  stress  as  that  exerted  at  the  point  of  weight ;  and  for  this 
same  reason  the  post  lever  moves  through  the  soil  at  the  surface  of  the  ground 
about  twice  as  far  as  at  the  lower  end  in  the  opposite  direction. 

Levers  of  the  Second  Kind. — An  examijle  of  a  lever  of  the  second  kind  may  be 

a  rod  or  a  pole  supporting  a  weight 
carried  by  two  men.  See  Fig.  37. 
If  the  points  are  four  feet  apart,  at 
which  the  two  men — whom  we  may 
call  P  and  F — grasp  the  pole,  and 
the  weight  is  a  pail  of  water  weighing 
thirty  pounds  swung  in  the  center 
of  the  pole,  each  man  would  exert  a  force  equal  to  fifteen  pounds.  In  other  words,  the 
force  exerted  at  W,  exactly  in  the  middle  of  a  lever  at  equilibrium,  would  be  twice 
that  at  the  fulcrum.  Here,  again,  we  have  the  same  result  as  shown  by  the  action 
of  a  lever  of  the  first  kind. 

Now,  if  you  please,  note  the  change  in  the  relative  magnitude  of  force  exerted 

at    fulcnmi    and    weight    when    the 
length  of  the  power-arm  is  shortened. 
See  Fig.  38.    If  P  grasps  the  rod  one 
foot  from  the  pail,  we  have  a  three- 
foot  lever  with  P  exerting  twice  as 
much    force    as    F,    which    may    be 
proven  by  the  law  of  levers,  i.  e., 
"power  and  weight  are  in  the  inverse  ratio  to  their  distance  from  the  fulcrum." 
Power-arm  of  the  above  lever  (3  feet)  is  to  W-arm  (2  feet )  as  weight  (30  pounds) 
is  to  P,  or  20  pounds;  which  leaves  10  pounds  to  be  sustained  by  F.    Therefore,  the 
force  exerted  at  weight  in  this  lever  is  three  times  that  at  the  fulcrum. 

Again,  if  P  grasps  the  rod  six 
inches  from  the  weight,  he  exerts  a 
force  equal  to  four  times  that  of  F — 
determined  by  the  same  law.  See 
Fig.  39.  Here  the  force  exerted  at 
weight  is  five  times  that  at  the 
fulcrum. 

When  we  apply  these  rules  to  our  post  lever  (with  which  the  author  has  chosen 
to  illustrate,  on  a  general  scale,  the  action  of  the  same  character  of  force  applied  to 
a  tooth),  we  can  see  that  the  inverted  V-shaped  opening,  caused  by  the  lower  end 
of  the  post  moving  in  the  opposite  direction  from  the  applied  power,  may  be  changed 
quite  decidedly  in  area  by  applying  the  power  at  different  points  along  that  portion 
of  the  post  above  the  surface.  For  instance,  when  power  is  applied  at  the  top  of  a 
four-foot  post  imbedded  one-half  its  length  in  the  ground,  the  movement  at  the 
lower  end  in  the  opposite  direction  will  be  about  one-half  that  at  the  surface  of  the 


Fir, .  39. 


w 

i} 


P 


CHAPTER  XIII.     PRINCIPLES  OF  MECHANICS  101 

grovmd  in  the  direction  of  the  power.  When  power  is  applied  one  foot  from 
the  ground,  or  at  a  point  one-hah"  the  length  of  the  exposed  end,  the  movement  at  the 
lower  end  will  be  al^out  one-third  that  at  the  surface,  and  when  applied  six  inches 
from  the  ground  (or  in  a  tooth  lever,  as  near  to  the  alveolar  margin  as  the  gum  will 
permit)  the  m(>\-cment  at  the  lower  end  will  be  about  one-fifth  that  at  the  surface. 
Teeth  as  Levers. — While  teeth  differ  in  shape  from  each  other  and  from  the 
post  lever  which  has  been  described,  and  while  their  alveolar  stirroundings  do  not 
present  a  uniformity  of  resistance  to  their  movement,  and  therefore  while  we  can- 
not calculate  force  and  motion  with  mathematical  acctiracy,  the  fact  that  they  are 
imbedded  one-half  their  length  in  a  yielding  substance  and  subject  to  the  freciucnt 
application  of  force  for  the  correction  of  irregularities,  the  only  way  we  can  approach 
an  exact  science  in  the  application  of  power  for  their  movement  is  to  consider  them 
as  levers  propelled  by  a  machine  doing  work  on  the  tissues  in  which  they  are 
imbedded. 

In  the  process  of  moving  a  tooth  by  inclination — in  a  lingual  direction,  for 
Fic.  40.  instance — there  are  two  principal  spheres  of  resistance  in  the 

socket,  i.  e.,  one  over  that  portion  of  the  wall  that  is  pressed 
upon  by  the  tendency  of  the  root  to  move  in  the  direction  of 
the  applied  force  "c,"  Fig.  40,  and  the  other  upon  the  opposite 
wall  at  the  apical  area,  that  is  pressed  upon  by  the  tendency  of 
that  portion  of  the  root  to  move  in  the  opposite  direction  "d." 
.  Within  the  boundaries  of  these  two  spheres  of  action,  the  force 
exerted  upon  the  resisting  surfaces  gradually  diminishes  as  they 
approach  each  other  until  a  certain  zone,  or  pivotal  point  "e,"  is  reached,  upon 
which  it  may  be  said  no  force  is  exerted  in  either  direction,  and  consequently 
no  movement  occurs  toward  or  from  the  direction  of  the  applied  power.  By  far 
the  greater  portion  of  the  force  is  expended  at  the  gingival  and  apical  boundaries 
of  these  two  spheres,  which  therefore  may  be  considered  as  the  true  points  of 
Fulcrum  and  Weight,  when  the  tooth  is  a  lever  of  the  first  and  second  kinds. 

Tooth  Levers  of  the  Second  Kind. — With  the  application  of  inclination  force 
at  any  point  upon  the  crown,  the  apical  area  of  the  alveolus  is  the  natural  ful- 
crum or  immovable  point,  and  the  gingival  area  that  of  weight  or  movement.  A 
tooth  is,  therefore,  naturally  a  lever  of  the  second  kind.  One  of  the  reasons  for  this 
is  due  to  the  greater  relative  stabiUty  of  the  apical  walls  of  the  sockets,  especially 
of  long  roots  which  penetrate  the  real  bone.  But  the  principal  reason  which  applies 
to  all  conditions,  and  is  determined  by  the  law  of  levers  is:  with  force  applied 
laterally  at  a  single  point  upon  the  crown,  only  one-half  to  one-fifth  the  amount 
of  power  can  be  exerted  in  this  way  at  the  apical  area  as  compared  to  that  of  the 
cervical. 

First  Kind. — When  retruding  force  is  applied  at  the  incisal  zone — "a,"  Fig.  40 — 
of  a  central  incisor,  about  one-half  as  much  power  is  exerted  in  the  opposite  direc- 
tion upon  the  alveolus  at  the  apical  sphere  of  its  influence  "d"  as  at  the  cervical, 


102  PART  IV.     TECIJMC  I'RISClPIJiS  OP   PRACTICE 

"c,"  and  if  applied  at  the  gingival  zone  of  the  crown,  the  force  in  the  opposite  direc- 
tion at  "d"  is  greatly  decreased.  Ccmsequently,  the  ayjieal  end  is  naturally  the 
fulcrum  or  immovable  ])oint,  and  the  tooth  a  lever  of  the  first  kind. 

( )n  the  other  hand,  in  proportion  to  the  resistance  at  the  alveolar  border  "c," 
this  point  also  becomes  a  fulcrum  with  tendency  to  move  the  apical  end  of  the  root 
in  the  opposite  direction.  The  said  spheres  of  action,  therefore — apical  and 
cervical — of  a  tooth  lever  under  the  influence  of  inclination  force  applied  to  the 
crown  are  both  fulcrums,  reacting  vipon  each  other  for  the  production  of  weight, 
work,  or  movement,  proportionate  to  the  conditions. 

Relations  of  Power,  Stress,  and  Movement 

The  relative  degree  of  force  exerted  at  these  spheres  of  action  is  largely  governed 
by  the  position  upon  the  crown  or  root  at  which  power  is  applied ;  while  the  actual 
movement  that  takes  place  is  further  governed  by  the  relative  stability  of  the 
resisting  spheres,  form  and  number  of  the  roots,  etc. 

If  a  tooth  (say  a  central  incisor)  were  a  true  lever  of  the  first  kind  with  its 
point  of  immovable  fulcrum  at  the  border  of  the  alveolus,  and  its  point  of  weight, 
work,  or  movement  at  the  apex,  or  again,  a  lever  of  the  second  kind  with  its  im- 
movable fulcrum  at  the  apex,  and  point  of  weight  at  the  alveolar  border ;  and  both 
with  the  same  possibilities  of  changing  the  length  of  the  power-arm  presented  by 
the  different  points  upon  the  crown  at  which  force  can  be  applied,  its  relation  of 
applied  forces  could  be  determined  with  mathematical  precision,  as  follows:  With 
power  applied  at  the  incisal  zone,  the  amount  of  force  exerted  at  the  apex  in  the 
opposite  direction,  in  either  case,  would  be  exactly  one-half  that  at  the  alveolar 
border,  providing  that  the  latter  was  equally  distant  from  the  other  two  factors, 
or  exactly  in  the  center  of  the  lever;  and  with  power  applied  at  the  gingival  border 
of  the  crown,  or  upon  the  so-called  power-arm  at  one-fourth  the  same  distance  from 
the  central  factor  of  the  lever,  the  force  exerted  at  the  apex  would  be  exactly  one- 
fifth  that  at  the  alveolar  border;  as  proven  by  the  examples  of  the  pail  and  lever 
of  the  second  kind. 

When  applied  to  inclination  movement,  this  law  of  levers  teaches  us  why  we 
obtain  a  more  ready  response  to  force  that  is  applied  at  or  near  the  occlusal  borders ; 
but  with  a  far  greater  tendency  toward  tipping  or  abnormal  inclination  of  the  crown 
than  if  applied  at  or  above  the  gingival  margins.  To  illustrate  this,  note  the 
dift'erent  movements  that  would  probably  take  place  in  a  central  incisor  by  apply- 
ing force  at  different  points  and  directions  upon  the  crown,  as  follows: 

With  retruding  power  applied  at  "a,"  Fig.  40,  the  relative  amount  of  force 
exerted  at  "c"  compared  to  that  at  "d"  would  be  as  two  to  one.  But  if  the  usual 
stability  of  the  cortical  surface  of  the  process  obtains  at  "c,"  quite  as  much  move- 
ment might  occur  at  "d"  in  the  opposite  direction;  and  in  either  event  a  minimum 
amount  of  power  would  produce  inclination  movement.  This  exainple  fairly  rep- 
resents the  activities  of  a  lever  of  the  first  kind. 


CHAPTER  XIII.    PRINCIPLES  OF  MECHANICS 


103 


With  protruding  power  applied  in  the  opposite  direction,  at  "f,"  Fig.  41,  the 
Fig.  41.  relative  stability  of  the  resisting  spheres  would  be  reversed,  and, 

according  to  the  law,  as  the  force  exerted  at  "g"  (or  "c")  would 
be  about  twice  that  at  "h"  (or  "d")  with  the  present  example  the 
apical  sphere  of  resistance  "h"  would  be  the  real  fulcrum,  with 
almost  if  not  qt:ite  the  entire  movement  at  "g,"  and  the  lever  that 
of  the  second  kind.     In  both  these  examples  a  niinimum  amount 
of  power  would  produce  inclination  movement. 
With  rctruding  power  applied  at  "b,"  Fig.  42,  the  relative  amount  of  force 
exerted  at  "c"  compared  to  that  at  "a"  would  be  as  five  to  one, 
and  even  greater  in  some  instances,  in  proportion  as  the  line  of 
force  approached  the  center  of  resistance.     With  this  example 
there   would   be   far  less   tendency   toward   inclination   move- 
ment, because  the  main  portion  of  the  power  would  be  distribtited 
to  the  posterior  wall  of  the  alveolus.     The  fact  also  that  it  re- 
ciuires  far  more  power  at  this  point,  and  above,  to  move  the 
tooth  is  of  the  greatest  importance  in  the  construction  of  stationary  anchorages. 
Approaching  a  Bodily  Movement. — With  power  apphed  above  the  point,  "b," 
at  "i,"  Fig.  43,  as  could  be  accomplished  by  attaching  to  the 
crown  a  rigid  root-wise  extension  or  bar,  the  line  of  force  might 
be  sufficiently  above  the  point  of  greatest  resistance  at  "c," 
to  exert  no  force  in  the  opposite  direction  at  the  apical  sphere. 
In  fact  a  more  or  less  bodily  movement  of  the  entire  root  in 
the  direction  of  the  force  would  probably  occur  in  some  in- 
stances, though  not  with  the  absolute  certainty  that  would 
scientific  control  of  the  force  for  this  character  of  movement. 
For  instance,  in  the  construction  of  an  appliance  for  the  retrusion 
or  retraction  of  the  incisors  with  a  traction  bow  extending 
from  molar  anchorages,  if  we  wish  the  least  movement 
possible  of  the  roots  in  the  opposite  direction,  the  bow 
should   rest   upon   the  incisors   as   near  to  the   gingival 
margins  as  the  gums  will  permit.    Usually  upright  bars 
are  soldered  to  the  bands,  and  these  extend  to  the  highest 
points  of  the  exposed  faces   of  the   crowns.     Grooves  or 
rests  are  cut  at  the    upper   ends    of  these   for  the   bow, 
enabling   it   to    span    the    interproximate    gingivae.      See 
Figs.    44    and    45.      Frequently    the    bars   are   extended 
above  the  gum  margins,  in  order  to  apply  power  that  is 
ociuivalent  to  direct  force  upon  the  roots  at  points  above 
the    margins    of    the    alveoli,    and    it    is    found    in    these 
procedures  of  the  greatest  importance  in  arriving  at  results 
for  which  they  are  designed. 


follow  the  more 
described  later. 


104  J'ART   /I'.     TI-.CIIMC   I'RI Ml I'l.l-.S  OF   I'RACTICIi 

It  is  not  necessary  to  multiply  descriptions  of  methods  relative  to  other  teeth 
and  conditions  where  the  important  principles  of  inclination  movements  may  be 
employed,  further  than  to  say  that  whenever  it  is  desired  to  avoid  producing  an 
al)normal  inclination  of  the  crowns  of  teeth  in  the  direction  of  the  applied  power, 
it  is  nearly  always  possible  to  take  advantage  of  some  effective  mechanical  prin- 
ciple. On  the  other  hand,  whenever  in  the  movement  of  a  crown  under  the  appli- 
cation of  a  single  force,  it  is  desired  to  move  the  root  in  the  opposite  direction,  the 
force  should  be  applied  as  near  as  possible  to  the  occluding  border.  This  is  espe- 
cially true  in  cases  of  protruding  crowns  of  the  superior  incisors,  with  a  retrusion 
of  the  roots;  of  which  the  common  cause  is  thumb-sucking — the  teeth  often  as- 
suming a  decided  labial  inclination,  with  the  production  of  a  depression  along  the 
upper  portion  of  the  upper  lip. 

Power  in  Relation  to  the  Possibilities  of  Movement 

It  has  been  shown  that  the  tendency  to  inclination  movement  or  tipping  of 
teeth  is  somewhat  in  proportion  to  the  nearness  to  the  (icclusal  zone  at  which  power 
is  applied.  There  is  another  catise  of  the  tipping  movement  that  is  too  frequently 
overlooked,  i.  e.,  power  applied  in  excess  of  the  possibilities  of  orthopedic 
movement. 

In  correcting  the  positions  of  malposed  teeth,  it  should  never  be  forgotten: 
first,  that  the  important  and  indispensable  part  of  the  operation  is  to  so  regulate 
the  force  that  the  normal  functions  and  healthful  conditions  of  the  teeth  and  sur- 
rounding tissues  are  preserved;  and  secondly,  that  nature  will  permit  their  move- 
ment, physiologically,  only  so  rapidly  as  she  is  alile  to  take  care  of  the  broken- 
down  tissue  of  retrogressive  metamorphosis  caused  by  pressure  of  the  tooth 
upon  the  walls  of  the  alveolar  socket.  The  rapidity  of  the  movement  will  be 
influenced  largely  by  the  age  of  the  patient,  and  will  differ  as  other  things  differ 
with  people. 

The  point  which  interests  us  may  be  stated  as  follows:  As  soon  as  the  applied 
force  overreaches  the  possibilities  of  natural  physiologic  changes,  the  surplus  is 
liable  to  spend  itself  in  producing  some  undesired  and  unlooked-for  condition.  In 
other  words,  nature  can  be  made  to  work  only  so  rapidly.  Any  attempt  to  force 
her  beyond  her  natural  powers  will  certainly  result — if  not  in  disaster — in  a  mis- 
direction, and  transference  of  the  surplus  force  to  other  parts  which  should  not,  and 
otherwise  would  not  be  disturbed. 

On  account  of  the  relatively  hard  surface  layer  of  the  alveolar  process,  there  is 
always  a  tendency  for  it  to  act  as  a  fulcrum  over  which  the  tooth  is  tipped;  but  for- 
tunately the  apical  region  of  bone  in  which  the  roots  are  imbedded  usually  presents 
sufficient  resistance  to  the  lessened  degree  of  force  at  this  point  for  it  to  remain 
as  the  true  and  immovable  fulcrum  of  the  lever  so  long  as  the  force  is  not  increased 
beyond  the  powers  of  resorption  in  other  portions  of  the  socket.  The  moment  this 
does  occur,  however,  the  border  area  of  the  alveolus  becomes  the  fulcrum,  while 


CHAPTER  XIII.     PRINCIPLES  OF  MECHANICS  105 

the  extra  force  is  delivered  at  the  end  of  the  root  in  the  opposite  direction  and  in 
exact  proportion  to  the  surplus  force. 

As  before  mentioned,  notice  the  action  of  the  force  of  an  oar  in  propelling  a 
boat  in  still  water.  If  only  sufificient  pressure  is  used  against  the  oar  to  permit 
the  water  to  pass  from  in  front  of  the  slow-moving  blade,  there  will  not  be  sufficient 
pressvire  at  the  fulcrtim,  or  oarlock,  to  overcome  the  inertia  of  the  boat;  but  im- 
mediately tipon  the  force  being  increased  above  the  possibilities  of  the  water  to  get 
nut  of  the  way,  the  fulcrum  of  the  lever  is  transferred  to  the  water  and  the  over-load 
of  surplus  force  is  delivered  at  the  oarlock  with  a  movement  of  the  boat.  There  is 
,  another  and  perhaps  more  forcible  example :  Drop  the  point  of  a 

crowbar  into  the  ground  at  the  side  of  a  large  cake  of  ice,  fixed 
immovably  in  place.  See  Fig.  46.  Now  if  we  heat  the  bar  and 
press  it  against  the  cake  with  only  sufficient  force  to  permit 
the  ice  to  melt  in  front  of  it,  little  or  no  change  of  position  will 
take  place  at  the  point  or  fulcrum  of  the  bar,  but  the  moment 
we  increase  the  pressure  above  the  melting  possibilities  of  the  ice, 
the  fulcrum  of  the  lever  is  transferred  to  the  cake  and  the  sur- 
plus force  is  delivered  at  the  point  of  the  bar,  with  a  tendency  in 
proportion  to  the  surplus  pressure  to  force  it  laterally  in  an  oppo- 
site direction  in  the  ground.  This  illustration  is  only  one  of  many 
conditions  which  may  be  and  often  are  produced  by  excessive  or 
misapplied  force  in  operations  for  correcting  irregularities  of  the  teeth. 

In  a  desire  to  hasten  an  operation,  dentists  will  commonly  push  the  amount 
of  force  to  the  limit,  not  fully  realizing  the  fact  that  the  orthopedic  movement  of 
the  teeth,  within  the  bounds  of  physiologic  safety,  cannot  be  made  to  move  faster 
than  the  processes  of  nature  will  permit,  however  much  force  is  exerted.  With 
force  properly  applied  near  the  gingival  borders  of  the  teeth,  they  will  usually  move 
by  inclination,  but  with  no  appreciable  movement  of  the  ends  of  the  roots  in  the 
opposite  direction.  When,  however,  the  magnitude  of  power  is  in  excess  of  the 
requirements  of  the  most  rapid  possible  movement  at  the  cervical  sphere  of  action, 
it  reacts  upon  the  apical  sphere  with  perhaps  the  production  of  a  movenient  in  the 
opposite  direction  with  far  greater  inclination;  and  one  which  would  not  have 
occurred  had  the  power  been  kept  within  the  bounds  of  the  possibilities  of  the 
movement  desired.  In  other  words,  the  cervical  sphere  of  action  being  unable 
to  respond  by  proportionate  movement  to  more  than  a  certain  degree  of  power, 
becomes  in  turn  a  stationary  fulcrum  to  the  excess  force,  which  causes  movement 
at  the  apical  end.  This  principle  of  force  is  important  when  applied  to  teeth 
which  are  moved  by  virtue  of  the  limited  possibilities  of  the  alveolar  process  "to 
get  out  of  the  way,"  and  it  is  also  applicable  between  all  alveolar  spheres  of  action 
and  fulcrum ;  as  for  instance,  the  general  movement  of  teeth  from  dental  anchorages. 
See  Stationary  Anchorages,  Chapter  XV. 

*Case— Dental  Review,  August,  1892. 


l()(j 


PART  n 


TECIIXIC   I'RI.XCII'LKS  OF   PRACTICE 


Till'  above  examples  are  presented  to  illvistrate  that  the  force  exerted  at  dif- 
ferent areas  of  the  alveoli  with  power  applied  at  different  points  upon  the  crown 
is  ([uite  similar  to  that  of  true  levers;  but  that  the  actual  movement  that  is  produced 
is  often  far  from  that  which  would  obtain  under  the  exact  conditions  and  require- 
ments of  mechanics.  The  difference  being  caused:  first,  by  the  fact  that  the  power 
cannot  be  exerted  in  the  socket  at  two  exact  points  of  weight  and  fulcrum,  but 
instead,  upon  the  broadened  spheres  of  the  alveolar  process  which  is  pressed  upon  by 
the  roots  of  the  teeth  under  the  influence  of  force  appliances  attached  to  the  crowns ; 
second,  l)y  the  variability  of  the  resisting  spheres;  and  third.  Ijy  the  peculiar  quality 
of  the  alveolar  process  to  move  only  in  accord  with  its  physiologic  possibilities, 
which  frequently  results  in  the  transference  of  the  force  of  action  to  points  of 
reaction. 

Furthermore,  these  principles  and  activities  of  force  are  quite  as  applicable 
in  the  movement  of  any  of  the  teeth,  and  especially  important,  as  it  is  always  pos- 
sible with  a  little  careful  thought  and  management  to  approximate  and  control  the 
relative  variability  of  probable  movement  at  the  resisting  spheres. 


ROTATING  MOVEMENT 

One  of  the  most  common  forms  of  dental  malposition  is  that  of  malturned 
teeth.  It  enters  more  or  less  into  every  class  of  irregularity,  particularly  that 
of  the  simple  and  complex  characters.  There  are  a  number  of  effective  methods  of 
correction,  applicable  to  different  conditions,  which  are  treated  at  some  length  in 
Chapter  XLVIII,  where  the  several  appliances  are  shown  with  full  description  of 
their  respective  force  activities.  There  are  certain  important  principles  in  the  ap- 
plication of  force  for  the  rotation  of  teeth  which  it  would  be  well  to  remember. 

Wherever  force  is  applied  for  the  rotation  of  a  tooth,  the  mechanical  power 
of  the  appliance  is  dependent  largely  upon  the  distance  from  the  central  axis  at 
which  the  force  is  exerted.     This  is  quite  important  when  applied  to  the  labial  teeth, 

the  peripheral  surfaces  of  whose  crowns  present 
points  of  attachments  that  greatly  dift'er  from  each 
"""'---.      other  in  this  regard. 

The  action  of  the  "wheel  and  axle"  as  one  of  the 
secondary  mechanical  powers  will  serve  to  illus- 
trate this  principle.  Fig.  47  demonstrates  at  a 
glance  the  mechanical  advantage  of  applying  a 
rotating  force  at  the  gingival  margins  of  incisors 
and  cuspids.  This  principle  is  especially  true  of 
the  spring  lever  rotator,  which  is  one  of  the  most 
convenient  and  effective  appliances  in  the  author's 
practice  for  nearly  all  cases  where  a  moderate  force 
is  sufficient.    See  Fig.  241. 


Fig.  47. 


CHAPTER   XI 11.     PRINCIPLES  OF  MECIIAXICS 


107 


Fig.  49. 


Spring  Lever  Rotator. — When  a  straight  resil-  ^^'-^^  '^'^^ 

ient  bar  is  bent  in  the  form  of  a  bow  and  its  ends 
are  immovably  attached,  the  only  force  which  it 
potentially  exerts  is  in  the  direction  of  the  arcs 

which  its  ends  would  inscribe  if  released  and  allowed  to 
return  to  equilibrivmi.    See  Fig.  48. 

If  one  end  is  fastened  to  a  stationary  point  or  anchorage, 
and  the  other  to  a  movable  body,  such  as  an  incisor  tooth, 
the  only  force  which  it  would  exert  upon  the  incisor  would 
be  in  the  direction  of  the  arc  which  that  end  would  inscribe 
in  returning  to  the  originally  straight  form  of  the  bar,  as 
shown  in  Fig.  49. 

If  instead,  the  distal  end  is  hooked  to  an  alignment  bow 
along  which  it  can  freely  ghde,  as  in  Fig.  50,  the  bar  will  then 
exert  the  additional  force  of  tooth  rotation.  See  Fig.  241. 
If  the  incisor  is  prevented  by  the  alignment  bow  from  re- 
sponding to  the  outward  spring  of  the  end  of  the  bar  to  which 
it  is  attached,  the  only  movement  of  the  tooth  will  be  that  of 
rotation  on  its  central  axis,  in  response  to  the  force  of  the 
bar  to  return  to  equililjrium ;  and  this  force  will  always  be  in 
proportion  to  the  freedom  given  to  the  bar  to  straighten  itself  by  the  distal  end 
gliding  along  its  attachment.    Therefore,  to  obtain  the  greatest  rotating  power  of 

a  spring  lever  rotator,  the  free  end  should  not  be  clasped  by 
a  tube  attachment,  as  shown  in  Fig.  49,  or  by  any  long- 
bearing  attachment,  as  the  friction  caused  by  the  spring  of 
the  bar  would  retard  its  rotating  movement. 

In  all  cases  where  this  appliance  is  employed,  an  align- 
ment arch-bow  is  indispensable  to  prevent  the  rotating  tooth 
from  being  forced  out  of  alignment.  The  bow  is  also  well 
adapted  for  the  gliding  movement  of  the  free  end  of  the 
rotating  lever,  with  a  proper  distribution  of  its  tangential 
force.  Frequently  the  reciprocally  reacting  force  exerted  by  a 
spring  lever  can  be  utilized  in  bringing  the  tooth  or  teeth  to 
which  it  is  attached  at  one  end,  or  both,  into  alignment. 
But  no  patient  should  be  allowed  to  leave  the  chair  with  appliances  of  this  kind 
attached  to  the  teeth,  without  the  controlling  power  of  an  alignment  bow  or 
other  effective  attachments  for  preventing  the  teeth  from  being  forced  out  of 
alignment. 

Whenever  a  single  rotating  force  is  applied  upon  one  side  of  a  tooth,  as  with 
levers,  ligatures,  pv;ll  and  push  screw-bars,  etc.,  there  is  also  the  tendency  toward 
inclination  movement  unless  prevented  by  an  arch  alignment  bow  or  other  means. 
Frequently  both  movements  are  demanded,  i.  e.,  the  rotation  of  a  tooth  while 


Fig.  50. 


108  PART   IV.     TECIINIC  J'R!.\C/ J'LJ.S  OF   J'NACTfCE 

forc'injj;  it  to  ali,y;nment.  Numerous  instances  will  be  shown  in  the  illustrations  of 
Specific  Methods  where  this  principle  is  taken  advantage  of. 

True  rotating  force  which  exerts  no  tendency  other  than  to  rotate  the  tooth 
upon  its  central  axis,  can  only  be  produced  by  reciprocally  acting  pull  and  push 
forces  applied  upon  opposite  sides  of  the  tooth.  This  principle  is  applicable  in  all 
cases  where  considerable  force  is  demanded  and  frequently  it  is  the  only  effective 
method.  The  appliances,  with  the  text  descriptions,  in  Chapter  XLVIII  so  per- 
fectly illustrate  this  principle  that  it  need  not  be  explained  here. 

One  of  the  most  modern  and  effective  forces  for  the  correction  of  malturned 
teeth,  and  for  nearly  all  the  malalignments  common  with  yovmg  patients,  is  through 
the  resilient  action  of  very  light  spring  arch-bows,  Nos.  24  and  25. 

Intrusive  and  Extrusive  Movements 

When  force  is  applied  in  the  line  with  the  long  axis  of  a  tooth,  toward  or  from 
the  apical  end  of  the  root,  it  tends  to  produce  intrusive  and  extrusive  movements 
respectively.  Movements  of  this  character  are  necessary  in  the  correction  of  Svipra 
and  Infra-occlusions,  and  in  Open  and  Close-bite  Malocclu.sions.  The  methods 
employed  are  fully  outlined  under  practical  treatment  of  these  cases. 

Intrusive  Movements  are  far  more  difficult,  because  they  can  only  be  accom- 
plished by  a  resorption  of  the  bone  forming  the  sockets  and  are  governed  largely 
by  the  age  of  the  patient. 

Extrusive  Movements  are  commonly  the  easiest  of  all  movements  of  the  teeth, 
and  when  performed  within  the  bounds  of  a  reasonable  application  of  force  there 
is  no  danger  of  rupturing  the  vessels  and  nerves  at  the  apical  foramina.  In  this 
movement  the  gum  rarely  if  ever  changes  its  relative  position  at  the  gingival  borders, 
the  movement  seeming  to  take  place  solely  by  stretching  the  pericemental  and  gum 
tissues.  Judging  from  the  difficulty  in  permanently  retaining  movements  of  this 
character  after  correction,  however,  we  are  led  to  the  conclusion  that  the  reforma- 
tive process  in  building  new  alveoli,  under  these  circumstances,  is  comparatively 
slow.    See  Chapter  XLVI. 


CHAPTER   XR" 

BODILY  MOVEMENTS 

As  has  been  explained,  when  force  is  appHed  to  a  tooth  for  its  movement  in 
a  right-angled  direction  to  its  central  axis,  it  practically  becomes  a  lever.  When 
a  push  or  pull  force  is  applied  at  one  point  upon  the  crown  for  its  inclination  or 
tipping  movement,  there  are  two  areas  of  resistance  in  the  socket — gingival  and 
apical — upon  which  the  strain  comes  from  opposite  directions.  These  are  the 
areas  or  points  of  fulcrum  and  work.  The  mechanical  advantages  in  all  levers  are 
in  proportion  to  the  increased  distance  between  the  point  at  which  power  is  applied, 
and  the  fulcrum,  and  the  decreased  distance  between  points  of  fulcrum  and  work. 
But  in  bodily  movements,  the  entire  alveolar  socket  is  the  area  of  work,  its  mathe- 
matical "point"  being  !ocated  at  the  center  of  its  alveolar  resistance,  while  the 
fialcrum  of  the  lever  is  now  placed  outside  of  the  socket  at  some  point  upon  the 
crown  through  the  medium  of  the  mechanical  device,  and  the  power  is  applied  at 
another  point  between  the  fulcrum  and  point  of  work. 

Many  fail  to  understand  or  appreciate  the  mechanical  principles  and  requirements 
of  bodily  movements  of  the  teeth.  For  instance,  we  often  see  the  published  state- 
ment that  a  single  small  arch-bow  or  bar  .036"  in  diameter,  that  is  rigidly  attached 
to  the  buccal  or  labial  surfaces  of  teeth,  can  be  made  to  move  them  bodily  through 
the  alveolar  process.  While  this  might  be  possible  with  very  young  children  when 
time  is  a  matter  of  no  importance,  it  is  not  practical  from  a  general  orthodontic  sense. 
This  principle  of  bodily  movement  may  be  fairly  illustrated  by  soldering,  or 
firmly  attaching  an  iridio-platinum  bar  to  a  firmly  attached  cuspid  band — the 
threaded  end  of  the  bar  resting  in  a  molar  anchorage;  the  object  being  to  move 
the  cuspid  bodily  in  a  mesial  direction. 

Fk;.  .51.  It  does  not  take  a  mathematical  calculation  for 

an  ordinary  mind  to  see  that  when  force  is  applied 
in  this  manner  instead  of  being  evenly  distributed, 
over  the  entire  mesial  or  distal  surface  of  the  socket, 
as  it  must  be  in  order  to  move  the  root  bodily, 
a  weak  and  short-bearing  attachment  of  that  kind  would  not  be  of  sufficient  rigid- 
ity to  stand  the  strain,  in  any  case  requiring  more  than  a  very  moderate  degree  of 
bodily  movement  for  young  patients.  The  upper  surface  of  the  bar  at  its  point  of 
attachment  may  be  regarded  as  the  point  of  applied  power,  and  the  lower  edge,  the 
fulcnmi,  the  whole  device  being  a  lever  of  exceedingly  low  mechanical  advantage, 
because  of  the  nearness  of  points  of  power  and  fulcrum  compared  to  that  of  weight, 
or  alveolar  resistance. 

109 


110  FART  IV.     TECllMC   I'lUXCIPLES  OF  FRALTICE 

^'°'  '^'^'  If  the  bar  is  widened  at  its  point  of  attachment 

to  the  cuspid  by  soldering  to  it  a  rigid  plate,  the 
mechanical  advantages  toward  a  bodily  movement 
would  be  increased  in  proportion  to  the  width  of  its 
attachment.  Fig.  52.  But  even  this  device  with 
its  absolutely  I'igid  bar  and  attachment  to  a  cuspid  would  be  found  in  practice  to 
be  very  defective,  becatise  the  tendency  toward  inclination  movement  of  the  cuspid 
would  exert  a  strong  extrusive  force  upon  the  anchorage,  and  as  an  extrusive  move- 
ment requires  far  less  force  than  any  other  movement,  especially  that  of  a  bodily 
niovement,  it  would  not  take  long  to  produce  a  supra-occlusion  oi  the  molars  that 
would  result  in  an  open-bite  malocclusion. 

Observe  how  this  illustrative  device  may  be 

Fig    .53  ...  . 

put  into  practical  form  by  causing  the  power  and 
fulcrum  forces  to  act  independently  of  each  other 
with  reciprocal  action  upon  the  anchorage  and 
movable  points  of  attachment  to  the  cuspid.  See 
Fig.  53. 
It  will  be  seen  by  this  method  that  when  force  is  applied  on  the  power  bar, 
any  inclination  inovement  of  the  cuspid  which  is  not  overcome  with  the  fulcrum  bar 
can  have  no  extrusive  tendency  on  the  anchorage,  because  of  the  movable  attach- 
ments of  the  bars.  Again,  the  reciprocal  action  of  the  push  and  pull  forces  upon 
the  molar,  nullifies  the  reactive  force  upon  the  anchorage,  and  consequently 
stabilizes  it.  The  main  advantage  is  the  perfect  control  of  the  bodily  movement 
of  the  cuspid. 

With  very  rare  exceptions,  lateral  force  applied  at  a  single  point  upon  the 
crowns  of  any  of  the  teeth,  and  especially  the  molars,  would  require  for  the  bodily 
movement  of  the  roots  in  the  direction  of  the  applied  power,  a  far  more  rigid  pro- 
pelling arm  and  grasp  of  the  crown  than  is  possible  with  all  ordinary  regulating 
appliances.  The  limited  area  upon  which  force  can  be  applied  to  a  tooth,  compared 
with  that  portion  imbedded  in  the  socket  and  covered  by  the  gum,  has  made  it 
next  to  impossible  to  move  the  apical  end  of  the  root  in  the  direction  of  the  applied 
power  in  that  way.  Nor  could  a  bodily  movement  ever  be  accomplished  for  the 
customary  cases  with  power  applied  through  the  medium  of  a  single  push  or  pull 
bar,  or  arch-bow,  attached  at  any  point  upon  the  crown,  however  near  the  gingival 
margin,  as  the  opposing  wall  of  the  alveolus,  near  its  margin,  would  receive  the 
magnitude  of  this  direct  force,  and  in  proportion  to  its  resistance  it  would  become 
a  fulcrum  exerting  a  tendency  to  move  the  apical  end  or  ends  of  the  roots  in  the 
opposite  direction. 

If  force  is  applied  at  "A"  in  the  direction  of  the  arrow  in  Fig.  54,  it  will  be 
principally  received  by  the  opposing  walls  of  the  alveolus  near  the  margin,  or  at 
"B,"  where  the  greatest,  if  not  the  only,  movement  of  the  alveolar  process  would 
occur,  but  in  proportion  to  the  resistance  of  the  labial  wall  it  will  become   a 


CHAPTER  XIV.     BODILY  MOVEMENTS 


111 


Fig.  54. 


Fig.  55. 


Fig.  56. 


fulcrum,  creating  a  tendency  to  move  the  apical  end  in  the  opposite  direction. 
This  would  also  be  true  if  a  single  force  is  applied  in  the  direction  of  the  arrow  at 

"A,"  in  Fig.  55,  except  that  it  would  be  distributed 
over  a  greater  area  of  the  alveolus  with  lessened 
tendency  to  move  the  root  in  the  opposite  direc- 
tion. But  if  in  the  construction  of  the  apparatus, 
the  incisal  end  is  prevented  from  moving  forward, 
or  its  movement  is  placed  vmder  positive  control, 
it  becomes  the  real  fulcrum  with  possibilities  of 
directing  the  power  toward  a  l^odily  movement  of 
the  entire  root. 
But  if  in  the  construction  of  the  apparatvis  a  static  fulcrum  is  created  outside 
of  the  alveolus  and  made  to  act  independent  of  the  osseous  imbedment  at  a  point 
near  the  occluding  or  incisal  end,  while  the  power  is  applied  as  far  root-wise  as 
permitted,  the  tooth  will  then  become  a  lever  of  the  third  kind  of  considerable 
mechanical  advantage  having  power,  directed  to  a  movement  of  the  entire  root  in 

the  direction  of  the  line  of  force. 

In  the  diagrammatic  drawing.  Fig.  56  shows 
the  principles  of  the  combination  for  a  bodily 
labial  movement  of  the  incisors.  The  power 
bar  "P"  exerting  a  push  force  of  considerable 
magnitude  for  extensive  movements  for  the 
older  class  of  patients,  should  be  as  large  as 
No.  13,  or  14,  to  prevent  its  springing  laterally, 
while  the  fulcrum  "F"  exerting  a  traction  force, 
need  be  no  larger  than  No.  23.  The  reaction  of  these  two  forces  from  opposite 
directions,  centered  in  the  same  anchorage,  neutralize  each  other  at  this  point  to 
the  extent  of  the  lesser  force.  When  they  are  equal,  or  exactly  reciprocal,  no 
distal  or  mesial  force  is  exerted  at  the  anchorage. 

Fig.  57  shows  the  combination  for  bodily 
lingual  movement  of  the  incisors.  It  will  be 
seen  that  the  direction  of  the  two  forces  is 
reversed.  The  power  bow  now  exerting  a  pull 
force  need  not  be  larger  than  No.  16,  while  the 
fulcrum  bow  now  exerting  a  pusli  force 
should  be  as  large  as  No.  16,  or  17.  For 
practical  apparatus,  see  Chapter  XXXVII. 
If  an  attempt  were  made  by  grasping  the  top  of  a  post  imbedded  one-half  its 
length  in  some  yielding  substance  with  the  view  of  moving  it  bodily  in  a  lateral 
direction,  it  might  be  found  that  the  upper  portion  could  be  easily  moved  back  and 
forth,  but  with  every  movement,  the  lower  end  of  the  post  would  move  in  its  im- 
bedment in  the  opposite  direction.    See  Fig.  35,  Chapter  XIII.    Again,  if  the  post 


Fig.  57. 


112  /MA'/'  /r.    rr.ciixic  rRiwiri.i'.s  (>/■  practice 

is  grasped  near  the  surface  of  the  ground,  it  will  require  far  more  force  to  move  it, 
because  of  the  lessened  mechanical  advantage,  but  even  then  the  lower  end  would 
move  in  the  opposite  direction.  If  now  the  top  of  the  post  is  grasped  by  one  hand 
and  prevented  from  tipping,  while  the  whole  force  of  the  other  is  exerted  at  the 
base,  the  difficulty  will  at  once  be  solved.  In  the  last  effort  an  independent  fulcrum 
is  established  at  the  top  of  the  post,  and  the  whole  mechanical  action  changed 
to  that  of  a  lever  of  the  third  kind,  with  the  entire  power  distributed  to  all  the  im- 
bedded portion  toward  a  movement  in  the  direction  of  the  force.  It  is  exactly  this 
principle  that  should  be  employed  for  the  bodily  movement  of  all  teeth.  When  it 
is  possible  to  apply  the  power  at  a  point  further  root-wise  than  the  gingival  border, 
through  the  medium  of  a  root-wise  bar  soldered  to  the  band,  or  a  rigid  extension 
of  the  band  attachment,  the  mechanical  advantage  of  the  lever  will  be  increased, 
and  the  force  upon  the  artificially  arranged  fulcrum  proportionately  lessened. 

A  study  of  these  principles  will  show  that  the  operator  has  perfect  control 
over  the  peculiar  character  of  movement  imparted  to  the  incisors.  For  instance,  in 
Fig.  55,  if  it  is  desired  to  bodily  move  the  incisors  forward  and  retain  the  same 
inclination  which  the  teeth  possessed  at  the  start,  the  distal  nut  of  the  fulcrum  bow 
should  be  judiciously  unscrewed  as  the  movement  progresses,  to  allow  the  incisal 
zone  to  move  forward  with  the  roots.  The  loosening  of  the  fulcrum  wire  can  be 
carried  to  such  an  extent  that  there  will  be  no  movement  at  the  apical  zone.  On 
the  other  hand,  by  exerting  a  traction  force  upon  the  fulcnmi  bow,  the  apical  zone 
can  be  protruded,  and  if  desired,  the  occlusal  zone  can  be  retruded.  Similar  rules, 
with  movements  reversed  are  applicable  in  bodily  retruding  the  incisors  with  the 
combination  shown  in  Fig.  57. 

In  the  early  introduction  of  '  he  above  principle  which  is  exactly  in  accord 
with  the  laws  of  mechanics,  the  author  was  severely  criticised,  and  the  principal 
contention  was  that  power  applied  vipon  a  rigid  root-wise  bar  soldered  to  an  incisor 
band,  as  shown  in  Fig.  56,  was  equivalent  to  applying  it  at  the  gingival  margin  of 
the  tooth,  in  as  much  as  the  extension  bar  was  attached  at  that  point,  and  because 
the  force  was  applied  through  this  medium.  They  seemed  to  forget  that  one  of  the 
basic  laws  of  physics  is:  "Force  always  acts  in  a  line  with  the  direction  of  its  move- 
ment," and  that  this  applies  equally  to  all  levers,  however  bent  or  crooked  the  bars, 
providing  they  be  rigid. 

Students  will  recognize  the  truth  of  this  principle  in  the  following  drawing: 

Force  applied  at  "A,"  Fig.  58,  in  the  direction  of  the  arrow,  upon  a  rigid  steel 
ring,  will  be  transmitted  to  "a,"  and  will  have  the  same  effect  and  direction  of 
influence  as  it  would  if  applied  at  "x."  This  will  also  be  equally  as  true  if  a  piece 
is  cut  out  of  the  ring  on  one  side — providing  it  is  rigid — as  at  "B-b."  This  being 
true,  the  same  principle  will  apply  at  "C-c"  and  "D-d."  The  latter  is  similar 
to  the  appliance  which  we  rigidly  attach  to  a  tooth  for  the  purpose  of  applying 
the  force  in  a  line  further  root-wise  than  would  be  possible  at  any  point  upon  the 
crown  proper. 


CHAPTER    XIV.     BODILY   MOVEMENTS 
Fig.  5S. 


113 


In  the  combination  for  bodily  moving  the  teeth,  through  the  possibihties  of 
estabhshing  an  independent  fulerum  at  the  occlusal  or  incisal  zone,  the  only  object 


Fir,,  -.n. 


// 


H  ' 


of  applying  the  power  at  a  point  upon  the  root  is  to  increase  the  mechanical  ad- 
vantage of  the  lever,  by  increasing  the  distance  from  points  of  power  and  fulcrum, 
which  proportionately  relieves  the  strain  upon  the  power  and  fulcrum  bows.    This 


Ill  PART   IV.     TECU.MC   I'RIXCII'LES  OF   PRACTICE 

is  a  feature  of  considerable  importance  with  rej^ulating  a])paratus  where  the  great- 
est possible  delicacy  of  the  appliances  consistent  with  strength  is  always  desirable. 

In  the  practical  application  of  these  principles  to  j^iractice,  Fig.  59  shows 
enlarged  drawings  of  the  bands  and  their  attachments  for  the  bodily  labial  and 
lingual  movements  of  the  upper  front  teeth.  F  F'  shows  the  power  applied  at  the 
gingival  margins,  which  is  the  common  method  for  patients  not  older  than  fourteen, 
requiring  a  bodily  labial  movement  of  the  front  teeth,  and  G  G'  for  the  older  class 
of  patients  where  the  greatest  possible  mechanical  advantage  is  necessary:  H  H' 
shows  the  form  of  attachments  for  the  bodily  lingual  movement  of  the  front  teeth. 

As  compared  to  these  scientific  principles  of  mechanics  which  have  been  ex- 
tensively and  successfully  employed  since  1891  for  the  bodily  movenient  of  front 

Fk,.  tiO. 


teeth  in  the  correction  of  all  characters  of  dento-facial  protrusions  and  retrusions, 
it  may  be  interesting  to  briefly  glance  at  Dr.  Edward  H.  Angle's  method  of  bodily 
movement  shown  in  Fig.  60. 

He  claims  that  a  platinum  gold  wire  when  rolled  to  a  ribbon  thickness  of 
about  .022"  and  a  width  of  .036"  and  employed  as  an  arch-bow  firmly  attached  to 
the  middle  of  the  labial  surfaces  of  the  incisor  crowns  with  bracket  attachments  as 
shown,  will  prevent  the  incisors  from  tipping  and  will  produce  a  bodily  labial 
movement ;  the  bow  being  attached  to  single  molar  anchorages.  The  upper  edge  of 
the  ribbon  where  it  engages  with  the  brackets  is  made  to  exert  a  tortional  spring 
force  upon  the  incisors.  Consequently,  the  only  force  toward  a  bodily  labial 
movement  at  the  apical  ends  of  the  roots  must  be  exerted  by  the  torsional  spring  of 
this  very  small  ribbon  bow,  the  upper  and  lower  edges  of  which  act  as  power  and 
fulcrum  with  a  very  low  mechanical  opportunity  compared  to  the  distance  and 
great  resistance  of  the  points  of  work.  Moreover,  no  more  than  a  very  moderate 
degree  of  labial  force  applied  at  the  anchorages  can  be  obtained  from  a  ribbon 
bow  of  that  size. 


CHAPTER   XIV.     BODILY   MOVEMENTS 


115 


Fig.  61  "A"  is  a  mesio-distal  view  of  Dr.  Angle's  method.  It  shows  by  the  two 
lower  arrows  the  approximate  distance  between  power  and  fvilcrum,  and  by  the 
upper  arrow,  the  distance  to  the  center  of  the  area  of  work.     "B"  shows  the  prin- 


FiG.  01. 


■>** »■ 


ciples  of  a  modification  by  the  author,  to  increase  the  mechanical  advantage  of  the 
method  by  employing  a  No.  18  bow  rolled  to  a  thickness  of  .020  and  a  width  of 
.050".  This  greatly  increases  the  comparative  distance  between  the  points  of  power 
and  fulcrum,  and  being  placed  at  the  gingival  margins,  it  decreases  the  distance  to 
the  area  of  work  or  alveolar  resistance,  both  of  which  greatly  increase  the  mechanical 
advantage.  Again,  the  arch-bow  being  rolled  only  over  its  incisal  dimensions,  as 
shown  in  Fig.  62,  the  protruding  power  of  the  bow  is  greatly  increased. 

Fig.  62. 


■^^^ 


This  torsional  method  of  bodily  movement  is  hardly  to  be  compared  with  the 
long  tried  effectiveness,  mechanical  advantages,  and  physiologic  control  of  the  reg- 
ular bodily  movement  apparatus,  the  principles  of  which  are  shown  in  Fig.  61, 
"C"  and  "D."  Note  the  relatively  increased  distances  between  power  and  fulcrum, 
and  decreased  distances  to  the  center  of  resistance  or  weight,  shown  by  the  arrows. 

The  bodily  disto-mesial  movement  of  buccal  teeth  to  close  spaces  after  extrac- 
tion so  as  to  leave  no  inverted  V-shaped  interproximate  space  to  pocket  food  is  of 
the  greatest  importance.  This  is  accomplished  by  ingenious  devices  for  applying 
the  power  upon  lingual  and  buccal  root -wise  extensions  aided  by  an  occlusal  screw 


116 


PART  JV.     TELllMC  J'NIMIFLE.S  Of  J'JiACTJCE 


bar  fulcnim  resistance,  or  by  long-liearing  telescoping  tubes  at  the  occlusal  area. 
See  "Stationary  Anchorages,"  Chapter  XV,  and  the  closing  of  "Abnormal  Inter- 
proximate  Spaces,"  Chapter  L.  Also  see  Figs.  266  and  268,  Chapter  L;  and  Fig. 
166,  Chapter  XXIX. 

The  ordinary  methods  of  expanding  narrow  dental  arches,  are  by  spring  arch- 
bows,  or  lingual  jacks,  the  forces  of  which  being  applied  upon  the  crowns  in  a  buccal 
direction,  produce  purely  an  inclination  movement,  with  the  result  that  the  teeth 
soon  close  only  on  the  lingual  cusps,  and  this  tends  to  drive  them  back  to  their  form- 

FiG.  f)3. 


er  malpositions,  unless  positively  retained.  Therefore,  except  in  those  cases  where 
the  buccal  teeth  are  lingually  incHned,  there  should  always  be  an  endeavor  to  produce 
a  bodily  buccal  movement.  One  of  the  most  practical  aids  toward  this  movement 
is  the  root-wise  extensions  soldered  to  the  buccal  surfaces  of  the  bands.  To  these, 
the  open-tube  attachments  are  soldered  to  the  extreme  root-wise  positions  permitted 
by  the  muscles.  When  high-grade  spring  arch-bows  No.  18  or  17  are  sprimg 
into  these  tubes,  the  line  of  force  is  far  nearer  to  the  center  of  alveolar  resistance  in 
the  sockets,  and  consequently  with  a  greatly  increased  tendency  toward  bodily 
expanding  movement . 

It  very  commonly  arises  that  this  expansion  arch-bow  is  threaded  at  the  ends 
for  nuts,  to  exert  distal  or  mesial  force ;  the  ends  resting  in  open-tubes,  which  may 
be  partially  closed  after  placing  the  bow.    The  bow  can  then  be  utilized  for  a 


CHAPTER   XIV.     BODILY   MOVEMEXTS  117 

labial  or  lingual  movement  of  the  front  teeth,  and  at  times  also,  as  a  power  bow  for 
bodily  movements. 

Fig.  63  illustrates  an  appliance  that  has  been  constructed  to  show  how  a 
combination  of  torsional  and  root-wise  forces  may  be  employed  in  the  bodily  expan- 
sion of  arches.  The  arch-bow  in  this  appliance  is  No.  19  special  spring  nickel  silver, 
rolled  distal  to  the  cuspids,  to  a  ribbon  form  of  about  %  its  diameter,  and  at  an 
angle — in  equilibrium — that  will  twist  the  ends  of  the  bow  one-quarter  to  one-third 
the  way  around  when  sprung  into  the  U  anchorage  tubes,  and  in  a  direction  so  that 
the  force  of  the  upper,  or  root-wise  edge  of  the  ribbon  will  be  exerted  in  a  buccal 
direction.  The  lingually  directed  force  of  the  lower  edge  is  supposed  to  be  more  than 
neutralized  by  the  direct  expanding  force  of  the  bow.  The  model  on  the  left,  shows 
the  position  of  the  arch-bow  at  rest  with  one  end  in  its  anchorage  tube,  in  a  position 
to  be  grasped  firmly  at  the  other  end  with  a  pair  of  pliers,  with  which  it  is  twisted 
while  carrying  it  to  its  seating  in  the  opposite  U  tube.  It  will  be  seen  that  this 
apparatus  may  be  constructed  to  produce  a  bodily  buccal  movement  on  one  side 
alone  if  so  desired,  by  leaving  one  eiid  round  to  be  carried  to  place  in  a  round  open 
anchorage  tube.  This  torsional  arch-bow  may  be  employed  as  a  pull  or  push  bow 
by  threading  its  ends  for  nuts  to  operate  in  connection  with  the  anchorage  tubes. 


CHAPTER  XV 

PRINCIPLES   OF   DENTAL   ANCHORAGES 

The  most  important  of  the  laws  of  force  in  the  mechanical  movement  of  mal- 
posed  teeth  is  Newton's  third  law:  To  every  action  there  is  an  equal  and  contrary 
reaction. 

Nowhere  is  this  law  so  important  as  in  the  application  of  force  in  dental  anchor- 
ages, and  in  all  movements  of  teeth  from  points  of  dental  resistance,  because 
whatever  the  magnitude  of  force  that  is  exerted  toward  the  correction  of  one  or 
more  malposed  teeth,  an  equal  force  must  always  be  exerted  in  the  opposite  direc- 
tion upon  the  tooth  or  teeth  that  are  chosen  for  the  bases  of  action.  While  the 
forces  exerted  at  points  of  action  and  reaction  are  always  equal,  the  relative 
amount  of  movement  that  is  induced  is  proportional  to  the  respective  resistances. 

As  the  amount  of  movement  in  proportion  to  the  resistance  is  largely  dependent 
upon  the  mechanism  employed  for  the  application  of  force,  and  consequently, 
upon  the  peculiar  construction  of  the  appliances  and  their  attachments,  a  perfect 
knowledge  of  the  principles  involved,  with  the  technics  of  construction  and  appli- 
cation of  dental  anchorages,  is  of  the  utmost  importance. 

Bands  for  anchorage  teeth  that  are  intended  to  sustain  considerable  force 
should  be  made  of  material  no  thinner  than  .005  ';  and  for  stationary  anchorages 
two  and  sometimes  three  adjoining  bands  should  be  soldered  firmly  together. 

The  ordinary  clamp-band  attached  to  a  single  molar  tooth,  and  also  the  long 
band  clamping  two  or  more  teeth  together,  are  not  stationary  anchorages.  In  fact, 
some  of  them  should  be  termed  "movable  anchorages,"  because  they  ofiEer  so  little 
resistance  to  inclination  movement,  especially  when  the  bands  are  thin,  or  are 
uncemented.  as  is  sometimes  advised;  for  even  when  well  supported  by  the  adjoining 
teeth  there  is  nothing  to  prevent  the  sliding  of  contact  surfaces,  which  is  the  main 
principle  of  anchorage  stability. 

It  may  be  laid  down  as  a  rule  that  all  single  band  anchorages  of  the  above  type 
will  surely  result  in  an  inclination  movement  of  the  teeth  to  which  they  are  attached 
if  much  force  is  applied.  A  band  that  is  clamped  around  a  tooth  with  a  screw 
has  no  superiority  in  sustaining  capacity  over  one  that  is  accurately  fitted, 
even  though  the  bands  be  of  the  same  thickness  and  both  cemented ;  and  the  claim 
that  "it  will  move  a  first  molar  bodily  through  the  process,  after  the  eruption  of  the 
second  molars,  if  it  moves  it  at  all,"  is  simply  absurd.  With  the  most  scientifically 
constructed  anchorage,  with  thick  molar  bands  reinforced  and  properly  supported 
so  as  to  thoroughly  distribute  the  applied  force  to  all  its  resisting  areas,  if  the  power 
is  applied  in  the  usual  way  on  the  crown,  the  molar  tooth  to  which  the  anchorage 

118 


CHAPTER  XV.    PRINCIPLES  OF  DENTAL  ANCHORAGES  119 

is  attached  is  rarely  if  ever  moved  bodily  in  a  mesial  or  distal  direction,  and  if 
too  much  force  is  applied,  there  is  always  danger  of  inclining  the  teeth  by  a  slight 
bending  or  yielding  in  the  rigidity  of  the  appliance  or  its  cement  attachments. 

If  one  will  study  from  a  mechanical  standpoint  the  anatomic  shapes  of  the 
first  and  second  molar  teeth — their  position,  inclination,  and  length  of  roots  in 
relation  to  their  natural  imbedment  in  the  alveoli — and  intelligently  note  the  direc- 
tion of  movement  which  each  root  will  take  in  its  socket  during  the  process  of 
inclining  the  tooth  mesially  or  distally,  and  again  if  he  will  note  the  resistance  which 
the  three  upper  roots  and  the  two  broad  lower  roots  offer  to  a  bodily  mesial  or 
distal  movement,  and  if  he  will  then  turn  his  attention  to  the  crowns,  their  smooth 
rounded  contours,  the  narrowness  of  the  coronal  zones  as  compared  to  the  length 
of  the  teeth  to  which  we  are  permitted  to  attach  bands — then  and  not  until 
then  can  he  appreciate  the  difificulties  of  preventing  inclination  or  of  producing 
bodily  movements  of  molars  with  the  force  applied  to  the  crowns  with  any  form 
of  attachment. 

By  "too  much  force"  is  meant,  more  force  than  the  limit  of  physiologic  tooth 
movement  requires.  This  surplus  force,  be  it  little  or  great,  added  to  the  already 
adequate  force  reacting  upon  the  anchorage,  may  be  sufificient  to  overcome  its 
stationary  inertia,  which  otherwise  would  not  have  occurred  with  an  exhibition  of 
greater  moderation  and  patience.  In  other  words,  the  active  end  of  the  machine 
becomes  the  inactive  anchorage  for  every  ounce  of  the  surplus  force,  because  its 
resisting  tissues  are  already  strained  to  their  fullest  extent,  and  are  now  reacting 
upon  the  original  anchorage  tissues  that  are  ready  to  move  as  soon  as  the  force  of 
reaction  becoines  sufficient  to  overcome  their  inertia. 

The  dissolving  and  bending  processes  that  are  induced  in  the  alveolar  process 
by  direct  pressure  of  the  roots  of  teeth  upon  the  surrounding  pericemental  tissues 
are  limited  in  their  possibilities  of  rapidity  of  movement.  And  when  we  go  beyond 
the  possibility  of  this  movement  with  greater  than  a  sufficient  force,  we  are  opposed 
by  the  same  sort  of  resistance  that  occurs  when  we  attempt  to  thrust  a  heated 
poker  into  ice  faster  than  it  is  possible  for  the  ice  to  melt  and  get  out  of  the  way  of 
its  movement;  with  the  result,  that  this  surplus  force  reacts  and  often  does  some- 
thing that  was  not  intended.  It  may  break  the  appliance,  strip  a  thread,  cause  the 
anchorage  attachment  to  give  way  and  the  teeth  to  incline,  and  perhaps  more  fre- 
quently than  anything  else,  produce  extrusive  movements  and  greater  inclination 
than  desired  of  the  teeth  we  are  trying  to  correct. 

The  same  simple  law  of  physics  which  applies  to  front  teeth  under  the  active 
stress  of  movement  applies  equally  to  anchorages.  When  lateral  force  is  applied  to 
the  crown  of  a  tooth  at  some  point,  with  a  hinge  movement  attachment,  that  tooth 
becomes  a  lever  of  the  second  kind,  with  its  natural  fulcrum  at  the  apical  end,  and 
with  its  greatest  stress  upon  the  alveolar  border.  If,  therefore,  we  do  not  exceed  the 
possibilities  of  movement  at  the  gingival  area  in  proportion  to  the  apical  inertia, 
we  may  get  no  movement  at  the  apical  end  of  the  tooth  in  the  opposite  direction. 


120 


PART  IV.     TRCIINIC  PRINCIPLES  OF  PRACTICE 


"'  '■'■  If  power  is  applied  at  "P,"  Fig.  64,  or  at  one  point 

on  the  crown  of  a  lower  molar  tooth  in  a  mesial 
direction,  the  principal  area  of  the  alveolus  which  is 
pressed  upon  will  be  that  of  the  mesial  root ;  the  great- 
est force  being  exerted  at  the  mesio-gingival  wall 
"a,"  and  a  lessened  force  in  the  opposite  direction 
at  the  disto-apical  wall  "c."  The  immovable  center 
of  the  circle  of  inclination  movement  in  this  instance 
would,  therefore,  be  at  "F,"  with  a  combination 
movement  of  the  entire  tooth  which  would  tend  to 
lift  the  distal  root  from  its  socket  with  a  moderate  degree  of  resistance  other  than 
that  of  its  membranous  attachments.  The  same  principle  will  also  apply  to  a  distal 
movement  of  these  teeth;  and  because  of  it,  molar  teeth,  which  are  unsustained 
by  adjoining  teeth,  offer  little  or  no  more  resistance  to  inclination  movement  than 
do  teeth  with  one  root. 

It  would  seem  that  the  three  roots  of  the  upper  molars  would  enable  them  to 
present  the  greater  resistance  to  inclination  movement,  but  it  has  been  found  that 
they  tip  quite  as  easily  as  the  lower  molars. 


Principles  of  Anchorage  Stability 

In  contemplating  the  construction  of  a  molar  anchorage  appliance  that  will 
prevent,  as  far  as  possible  a  movement  of  the  included  teeth,  the  principal  object 
should  be  to  construct  the  device  so  that  the  great  tendency  of  the  crowns  to  tip 
will  be  prevented.  If  this  is  fully  accomplished  and  the  tooth  or  teeth  are  held  in 
an  upright  position,  the  applied  force  will  be  equally  distributed  over  the  entire 
mesial  or  distal  surfaces  of  the  alveoli  for  all  the  roots,  increasing  the  stability  of 
the  anchorage  to  an  incalculable  degree.  If  the  appliance  is  loosely  attached  to 
the  teeth  or  permits  the  slightest  hinge  movement,  as  would  arise  from  a  remov- 
able crib  or  a  single  uncemented  band  that  encircles  two  or  more  teeth,  there 
would  be  nothing  to  prevent  this  tipping  tendency;  though  stich  an  anchorage 
might  be  sufficient  for  many  purposes,  if  attached  to  a  sufficient  number  of  teeth 
and  the  applied  power  always  less  than  their  combined  natural  inertia.  But 
instances  frequently  arise  in  the  regulation  of  teeth  where  it  is  eminently  desir- 
able to  obtain  an  anchorage  of  the  greatest  possible  stability.  When  it  is  neces- 
sary to  employ  the  back  teeth  as  a  stationary  base  for  a  considerable  movement 
of  front  teeth,  two  or  three  teeth  should  be  included  in  the  grasp  of  the  anchorage 
appliance. 

The  addition  of  a  second  tooth  to  the  anchorage,  united  scientifically,  will 
far  more  than  double  its  stabilit};  by  the  support  which  the  two  teeth  can  be  made 
to  give  to  each  other  through  a  proper  construction  of  the  appliance;  on  the  same 
principle  that  the  strength  of  a  T  or  a  double  T  girder  is  increased  far  out  of  pro- 
portion to  the  difference  in  the  added  material,  over  that  of  a  plain  girder. 


CHAPTER  XV.     PRINCIPLES  OF  DENTAL  ANCHORAGES 


121 


^'"^"  '"•  This  principle  is  well  illustrated  by  the  simple 

mechanical  methods  adopted  in  constructing  the 
terminals  of  wire  fences.  If  the  two  terminal  posts 
were  united  by  parallel  bars  which  permitted  a  hinge 
movement  at  their  attachments  as  shown  in  Fig. 
65,  their  movement  would  depend  solely  upon  the 
united  stability  of  their  imbedment  in  the  ground, 
but  with  a  single  bar  placed  as  shown  in  Fig.  66, 
the  stability  of  the  terminal  is  seen  to  be  greatly 
increased,  because  inclination  movement  of  the 
terminal  post  is  obstructed,  nearly  all  the  stress  of 
the  wires  now  being  exerted  at  the  base  of  the  second 
post.  This  device  is  sufficient  for  all  ordinary  pur- 
poses of  wire  fence  building.  If  necessary  the 
terminal  stability  of  the  fence  could  be  greatly 
increased  by  attaching  a  second  bar  as  shown  in 
Fig.  67,  which  would  absolutely  prevent  the  slight- 
est inclination  movement  of  either  post,  and  es- 
tablish an  immovability  to  the  extent  of  a  power 
sufficient  to  pull  their  imbedded  ends  bodily  through 
the  ground. 
The  application  of  this  principle  is  exactly  what  we  endeavor  to  apply  in  the 
construction  of  stationary  anchorages. 


Fig.  07. 


¥u..  f„S. 


Stationary  Anchorages 

In  the  construction  of  stationary  dental  anchorages,  banding,  material  should 
be  selected  that  is  .005'  or  .0056"  in  thickness  (No.  36  or  35  gauge),  and  as  wide  as 
the  teeth  will  permit.    When  these  are  soldered,  festooned,  contoured,  and  fitted  to 

the  teeth  chosen  for  anchorages,  take  a  plaster  impression 
of  each  anchorage  separately,  using  the  anchorage  trays 
shown  in  Fig.  68,  or  similar  trays  which  can  be  easily  made 
of  sheet  lead;  and  then  use  only  sufficient  plaster  to  cover 
the  bands.  Carefully  remove  the  bands  from  the  teeth  with 
the  band-removing  plier,  to  avoid  distorting  their  shape, 
and  place  them  accurately  in  the  impressions.  See  that  the 
proximal  surfaces  are  forced  closely  together,  and  the  joints 
filled  with  hot  wax,  and  after  luting  with  liquid  plumbago, 
fill  with  investing  plaster,  forming  small  casts  of  only  sufficient  size  to  hold  the 
bands  in  place  during  the  soldering  process.  Solder  should  be  flowed  between 
the  bands,  uniting  their  approximal  surfaces  and  filling  the  V-shaped  spaces 
on  either  side.  To  more  perfectly  reinforce  the  stability  of  the  appliance,  fit  and 
solder  to  the  lingual  surfaces  a  piece  of  No.  16  hook  wire  in  the  form  of  a  yoke,  in 


122 


PART  IV.     TECIIXIC  PRJ.XCIJ'LES  OF   PRACTICE 


Fig.  60. 


addition  to  the  bviccal  tube  or  tubes  to  be  attached  for  the  power  bars  or  traction 
bows  for  the  movement  of  the  anterior  teeth. 

In  attaching  the  buccal  tubes,  the  ad,vantage  of  applying  the  power  as  near  the 
gingival  margin  as  possible  should  be  remembered.  Whenever  greater  stability 
is  demanded,  the  power  tubes  should  be  placed  further  root-wise  in  relation  to  the 
gingival  margins,  as  shown  in  many  illustrations  of  apparatus  throughout  this 
work.  This  is  one  of  the  most  advanced  and  practical  principles  in  the  construction 
of  stationary  anchorages,  and  in  fact  in  all  conditions  where  an  inclination  move- 
ment is  to  be  avoided. 

Root-wise  Anchorages. — In  nearly  all  cases  in  the  author's  practice  when 
considerable  anchorage  force  is  demanded  and  consequent  greater  stability  of  the 
anchorages,  the  tubes  for  sustaining  the  main  force  of  the  arch-bows  or  bars  are 
attached  to  root-wise  extensions,  which  places  the  strain  nearer  the  center  of  alveo- 
lar resistance,  and  thus  by  nullifying  the  tendency  to  inclination  movement  in- 
creases the  stability  of  the  anchorage. 

These  root-wise  anchorage  extensions  were  for- 
merly made  of  swaged  or  fitted  plates  soldered 
to  the  buccal  and  lingual  surfaces  of  the  bands,  which 
conformed  to  and  nearly  touched  the  gum  surfaces. 
But  because  this  method  occasioned  insanitary 
pockets  for  decaying  foods,  it  is  now  wholly  replaced 
by  the  following  improved  method,  which  has 
the  advantage  of  being  far  easier  to  construct  and 
fit.  In  Fig.  69,  the  root-wise  attachments  are  made 
of  No.  16  wire  rolled  to  about  two-thirds  its  diam- 
eter. With  the  anchorage  bands  mounted  on  investment  models  of  the  teeth,  the 
prepared  wire  is  cut  in  pieces  about  one-half  inch  long,  and  bent  to  fit  the  buccal 
siu-faces  of  the  bands  and  gum  as  shown,  and  at  proper  distances  apart  to  rigidly 
support  the  long-bearing  power  tubes.  When  these  are  soldered  in  position  and  the 
bands  are  soldered  together  with  a  reinforcement  flow,  the  positions  of  the  tubes 
are  marked  and  deeply  grooved  to  obtain  firm  seating  when  soldered. 

The  size  and  character  of  the  tubes  are  regulated  by  the  needs  of  the  case. 
For  instance,  if  the  anchorage  is  for  the  bodily  labial  or  lingual  movement  of  the 
front  teeth,  the  root -wise  or  gingival  tube  is  for  the  power  arch-bow  and  the  occlusal 
tube  is  for  the  fulcrum  arch-bow.  In  retrusive  inclination  movement  of  the  front 
teeth  after  the  extraction  of  the  first  premolars,  and  when  it  is  very  necessary  not 
to  disturb  the  buccal  occlusion,  as  would  arise  with  a  single-band  anchorage,  or  that 
might  occur  with  an  ordinary  two-band  stationary  anchorage,  the  root-wise  appli- 
cation of  the  greatest  force  will  be  found  to  be  invaluable.  If  the  object  is  to  re- 
trude  the  cuspids  with  a  traction  bar  and  with  a  traction  arch-bow  encircling  the 
front  teeth,  the  gingival  tube  should  be  chosen  for  the  cuspids,  and  the  occlusal 
tube  for  the  traction  arch-bow. 


CHAPTER  XV.    PRINCIPLES  OF  DENTAL  ANCHORAGES  123 

In  the  final  finishing  after  the  anchorage  is  removed  from  the  model  and  boiled 
out,  the  projecting  ends  of  the  bars  and  all  excess  material  is  cut  away.  In  fitting 
this  anchorage  to  the  teeth  preparatory  to  cementing  it.  the  positions  of  the  tubes 
in  relation  to  the  gum  surfaces  should  be  finally  adjusted  by  bending  their  root-wise 
supports. 

When  a  stationary  anchorage  of  this  character  is  fitted  and  cemented  to  the 
teeth,  it  will  tend  to  hold  them  rigidly  in  its  grasp  in  an  upright  position.  If  the 
bands  are  thin  and  narrow,  or  the  apparatus  is  not  sufficiently  reinforced,  or  if  for 
any  reason  there  is  a  lack  of  absolute  stability  in  the  work  or  its  attachments,  the 
slight  yielding  of  its  integrity  under  great  strain  permitting  inclination  movement, 
will  cause  the  bands  to  break  loose  from  their  attachments. 

Sustained  Anchorages 

Conditions  not  infrequently  arise  where  it  is  necessary,  in  correcting  a  malposi- 
tion, to  employ  an  isolated  molar  for  an  anchorage.  In  protruding  cases,  where  the 
first  molar  has  been  extracted,  for  instance,  and  the  third  molar  has  not  erupted, 
though  the  main  forces  may  be  the  occipital  and  intermaxillary,  it  nevertheless  is 
necessary  to  employ  the  single  molars  for  anchorages,  if  for  no  other  reason  than  to 
support  the  bow  and  retain  the  movement  as  it  progresses.  One  cannot  expect  much 
resistance  from  a  single  isolated  molar  whose  inclination  movement  is  not  prevented, 
and  even  where  it  is  wholly  prevented,  much  anchorage  force  will  always  tend  to 
partially  extrude  or  lift  it  from  its  socket.  If  properly  sustained,  however,  it  will 
answer  the  purposes  of  a  moderate  degree  of  force,  perhaps  sufficient  to  move  the  pre- 
molars distally,  one  at  a  time,  with  elastics,  and  also  to  sustain  and  retain  the  move- 
ment of  a  retruding  bow  which  is  acting  on  the  front  teeth  propelled  by  other  forces. 

In  the  construction  of  the  appliance,  the  same  rules  should  be  fully  observed 
that  apply  to  sustaining  the  stability  of  all  anchorage  teeth,  i.  e.: — (1)  The  bands 
should  be  wide  and  thick  so  as  to  possess  a  firm  grasp  of  the  crown;  (2)  the  en- 
gaging tubes  should  be  firmly  soldered  at  the  gingival  margins,  or  upon  root-wise 
extensions;  (3)  the  tubes  should  be  of  sufficient  length,  strength,  and  size  to  carry 
rigid  inflexible  traction  bars  or  arch-bows  for  communicating  the  force,  and  thus 
prevent,  as  far  as  possible,  the  slightest  inclination  movement  of  the  anchorages. 

A  principle  which  the  author  presented  at  the  meeting  of  the  American  Dental 
Association  in  1907,  for  sustaining  a  single  molar  anchorage  is  as  follows: 

"Instances  frequently  arise  where  only  one  tooth  can  be  used  for  an  anchorage 
on  one  or  both  sides  of  the  mouth.  These  teeth  not  being  supported  by  the  adjoin- 
ing teeth  will  readily  tip  if  not  properly  sustained.  In  fact,  a  molar  tooth  that  is 
allowed  to  tip  will  oft'er  but  little  more  resistance  to  force  than  a  premolar,  but  if 
sustained  in  an  upright  position  its  bodily  stability  will  greatly  increase  its  re- 
sistance to  movement.  When  a  single  isolated  molar  is  used  for  an  anchorage  attach- 
ment, the  band  should  be  wide  and  thick,  fitted  and  cemented  as  carefully  as  a  crown, 
with  rigid  attachments  for  inflexible  extensions.    However  perfect  the  band  and  its 


124 


PART  IV.     TECHNH     I'lil \CI PLES  OF   PRACTICE 


attachments,  if  a  flexible  traction  wire  is  used  to  transfer  the  power,  no  obstruction 
is  oft'ered  to  the  tipping  tendency  of  the  molar.  The  same  is  trvie  with  an  inflexible 
power  rod  if  the  band  is  thin,  narrow,  and  yielding,  or  in  any  way  movable  upon 
the  tooth,  or  if  the  power  tube  is  short  and  loosely  fitted  to  the  rod." 

Ph..  70.  Where    great    immobility    of    a 

single  anchorage  tooth  is  required, 
use  for  banding  material  nickel  sil- 
ver or  platinized  gold,  .0035"  thick, 
and  as  wide  as  the  tooth  will  permit. 
When  this  is  contoured  and  fitted, 
solder  to  the  buccal  surface  a  long 
bearing  power  tube  at  the  gingival 
margin.    See  Fig.  70. 

The  power  tube  should  extend 
forward  to  the  first  premolar  resting 
upon  narrow  projecting  hooks  solder- 
ed to  the  premolar  bands,  as  shown. 
This  will  add  greatly  to  the  stability  of  the  anchorage.  It  will  be  seen  that  any 
tendency  of  the  molar  to  tip  forward  will  carry  the  mesial  end  of  the  tube  almost 
directly  toward  the  roots  of  the  premolars,  the  movement  being  prevented  by  the 
rests.  Nor  will  such  a  device  offer  any  special  obstruction  to  the  distal  movement  of 
the  premolars — the  rests  sliding  along  the  tube. 

In  addition  to  this,  a  flattened  rigid  bar  may  be  soldered  to  the  lingual  aspect 
of  the  molar  bands  to  rest  upon  hooks  attached  to  the  premolars  as  shown.  This 
is  especially  applicable  where  it  is  desired  to  correct  a  protrusion  with  a  small 
flexible  traction  bow  encircling  the  teeth,  or  even  in  combination  with  more  in- 
flexible buccal  devices.  Again,  it  may  be  desired  to  move  the  premolars  distally 
to  relieve  a  crowded  maleruption  of  the  cuspids,  but  with  no  lingual  movement  of 
Fii;.  71.  the  incisors.    See  Fig.  71.    In  addition  to  the  long- 

bearing  lingual  tube  sustaining  the  single  molar 
anchorage  through  the  medium  of  the  lingual 
push  bow  resting  in  the  incisor  hooks,  the  doubly 
reinforced  and  sustained  anchorage  may  carry  a 
buccal  tube  soldered  to  root-wise  extensions  for  a 
traction  bar  to  the  malposed  cuspids,  and  also 
hooks  for  the  attachment  of  elastics  to  move  the  premolars  distally. 

A  similar  device  is  especially  applicable  for  children  who  have  inherited  a 
decided  protrusion  of  the  lower  teeth.  The  lingual  supporting  tubes  should  be 
sufficiently  large  to  allow  the  ends  of  the  bow  to  easily  glide  into  them  as  the  incisors 
are  forced  back  with  the  labial  traction  bow.  A  practical  result  in  the  application  of 
this  method  of  treatment  with  a  full  description  of  the  apparatus,  will  be  found  in 
Chapter  XLIV. 


CHAPTER   XV.     PRrXCIPLES  OF  DEXTAL   AXCHORAGES  125 

Reciprocating  or  Movable  Anchorages 

Dental  anchorages  may  be  considered  as  any  point  of  resistance  which  is  made 
to  receive  the  reaction  of  the  force  required  for  the  movement  or  correction  of 
malposed  teeth.  Wherever  it  is  possible  to  do  so,  these  points  of  resistance  should 
be  chosen  with  a  view  to  utilizing  the  reactive  force  for  a  reciprocal  movement  of 
other  teeth  that  require  correction.  This  is  one  of  the  most  practically  scientific 
laws  of  orthodontia,  though  sadly  neglected,  and  one,  moreover,  that  is  applicable 
in  some  form  in  almost  every  case  of  irregularity. 

In  the  choice  or  invention  of  a  regulating  apparatus,  after  the  several  required 
movements  of  the  case  have  been  determined,  a  careful  study  of  the  demands 
with  the  reciprocating  possibilities  in  view,  will  present  surprising  opportunities 
for  its  application.  This  will  be  found  well  exemplified  in  the  details  of  regulating 
apparatus  presented  in  this  work.  Instances  arise  where  it  is  eminently  desirable 
to  move  the  buccal  anchorage  teeth  mesially  or  distally  to  correct  occlusion  by  the 
same  force  that  is  used  to  protrude  or  retrude  the  front  teeth.  This  is  accomplished 
purely  by  the  method  in  which  force  is  applied  through  the  peculiar  construction  of 
the  appliances  that  permits  or  induces  inclination  or  bodily  movement  of  the  anchor 
teeth.  Nowhere  is  it  more  applicable  than  in  that  common  irregularity  which  is 
characterized  by  maleruption  of  the  cuspids,  shown  in  illustrations  of  apparatus  in 
Class  I  of  this  work. 

It  will  be  seen  by  a  number  of  the  appliances  that  the  reaction  of  the  force  to 
protrude  the  front  teeth  in  opening  spaces  for  the  cuspids,  is  received  upon  the 
premolar  attachment  whose  peculiar  construction  is  such  that  the  force  of  reaction 
is  applied  at,  or  near,  the  occlusal  zone,  and  as  near  as  possible  to  the  line  which 
bisects  the  central  axis,  with  a  tendency  to  produce  distal  inclination  without  rota- 
tion ;  the  whole  apparatus  being  calculated  to  utilize  to  the  fullest  extent  the  reac- 
tive force  from  the  front  teeth,  in  moving  the  buccal  teeth  back  to  normal  occlusion 
while  opening  the  spaces  for  the  alignment  of  the  cuspids. 


CHAPTER   XVI 
PRINCIPLES   OF    INTIiRMAXILLARV   AND   OCCIPITAL   FORCE 


Intermaxillary  Force 

One  of  the  most  important  methods  of  applying  force  in  the  regulation  of  teeth, 
and  one  which  is  now  recognized  as  an  indispensable  factor  in  modern  orthodontia, 
is  the  Disto-mesial  Intermaxillary  Force.  This  principle,  together  with  the  principle 
of  bodily  movement  of  teeth,  was  introduced  by  the  author  at  the  February  1893 
meeting  of  the  Chicago  Dental  Society,  and  at  the  International  Dental  Congress  in 
August  of  the  same  year.*  It  essentially  consists  in  the  attachment  of  elastic  rubber 
bands  from  the  cuspid  area  of  one  jaw  to  distal  buccal  points  upon  the  molar  area  of 
the  other,  for  the  purpose  of  producing  a  distal  or  mesial  movement  of  the  buccal 
teeth  of  one  jaw,  or  a  reciprocal  distal  and  mesial  movement  of  both  in  correcting  a 
disto-mesial  malocclusion  of  the  buccal  teeth,  and  as  an  aid  in  correcting  protrusions 
and  retrusions  of  the  front  teeth.  Throughout  practical  treatment  of  malocclusion 
will  be  found  many  illustrations  showing  different  methods  for  applying  this  force. 

The  peculiar  application  and  action  of  disto-mesial  intermaxillary  force  in 
orthodontia,  is  quite  distinctive  in  its  character,  and,  moreover,  decidedly  different 
from  all  forms  of  direct  intermaxillary  force  that  have  been  used  in  various  ways 
for  many  years. 

The  rubber  bands  that  are  well  adapted  for  intermaxillary  force  are  known  to 
the  trade  as  "election  rings,"  and  can  be  purchased  in  two  or  three  sizes  at  almost 
any  rubber  house.  Where  greater  force  is  required,  two  may  be  employed  or  the 
single  ring  may  be  doubled  or  looped  twice  upon  the  hooks. 

The  action  of  these  small  elastic  bands  exerting  a  continuous  force  upon  the 
teeth  of  youths,  will  at  times  accomplish  results  that  are  surprisingly  remarkable. 
Moreover,  the  ease  and  facility  with  which  the  elastics  are  adjusted  and  worn  by 
even  the  little  patients  uninterruptedly — even  while  eating — proves  the  practical 
applicability  of  this  force  in  the  regulation  of  teeth. 

This  method  of  applying  force  is  particularly  useful  in  all  cases  of  general 
protrusion  and  retrusion,  and  especially  in  cases  of  protrusion  of  the  teeth  of  one 

*As  the  origination  of  the  Intermaxillary  Force  has  been  claimed  by  others,  and  as  it  was  erroneously  named 
the  "  Baker  Anchorage"  by  Dr.  Angle  nearly  ten  years  after  it  had  been  quite  extensively  published  by  the  author 
and  employed  by  many  prominent  dentists,  the  reader  who  is  interested  in  the  historical  part  of  the  subject  is  re- 
ferred to  the  articles  entitled  "  Origin,  Use  and  Misuse  of  the  Intermaxillary  Force,  "  published  in  the  Dental  Cosmos, 
May  1904,  and  "Rise  and  Development  of  Intermaxillary  Force,"  published  in  the  Dental  Cosmos,  May  1907. 
The  fact  that  the  voluminous  evidence  presented  in  these  papers,  which  pertained  to  published  proceedings  of  pro- 
minent dental  societies,  and  the  historical  acts  and  statements  of  prominent  living  dentists,  has  never  been  contro- 
verted, except  by  bald  assertions  and  untrutliful  claims  unsuslained  by  the  slightest  attempt  to  produce  legitimate  evi- 
dence, is  sufficient  in  itself  to  place  the  honor  where  it  belongs. 

126 


CHAPTER   XVI.     INTERMAXILLARY   AXD  OCCIPITAL  FORCE 


127 


jaw,  and  retrusion  of  those  of  the  other  where  the  full  reciprocating  activities  of  the 
force  can  be  titilized.  When  properly  applied  in  this  way  to  the  teeth  of  youths, 
the  correction  of  malocclusion  and  facial  contours  is  found  to  be  easily  accom- 
plished in  numberless  instances  that  would  have  been  considered  at  one  time  im- 
possible without  extraction.  Frequently  the  teeth  are  moved  by  this  force  alone 
one-half  the  width  of  a  cusp,  or  reciprocally  the  full  width  of  a  premolar  which  is 
equivalent  to  the  operation  of  "jumping  the  bite." 

Fig.  72. 


In  Figs.  72  and  73,  the  facial  and  dental  casts  on  the  left  show  the  beginning 
malocclusions  of  four  cases  in  practice  whose  diagnosis  places  them  in  Division  1  of 
Class  II — "retrusion  of  the  lower  denture  with  upper  normal  or  nearly  so."  It  will 
be  seen  in  all  of  these  cases  that  there  is  a  full  distal  malocclusion  of  the  lower  buccal 
teeth  in  relation  to  the  upper,  with  the  usual  malrelation  of  the  front  teeth.  On  the 
right  are  shown  the  finished  cases  with  the  dentures  in  normal  occlusion,  and  the 
facial  outlines  corrected,  the  work  being  mainly  accomplished  with  the  intermaxil- 
lary force  in  shifting  the  dentures  to  a  normal  occlusion.  See  also  Figs.  173  and 
174,  Chapter  XXXI. 

For  the  protrusive  or  retrusive  movements  of  the  teeth  of  one  jaw  with  the 
intermaxillary  force,  as  explained  elsewhere,  the  force  of  the  reaction  should  be  dis- 
tributed to  the  teeth  of  the  opposing  jaw  so  as  to  avoid  their  movement.     If  a 


128 


/MA'/'   J\  .     TKCn.MC  J'R/.\C1J'LJl.S  Of   J'RACTKE 


retrusive  movement  of  the  teeth  of  one  jaw  be  required,  with  no  mesial  movement 
of  the  opposing  buccal  teeth,  the  hooks  for  the  attachment  of  the  elastics  to  the 
opposing  jaw  should  be  placed  at  the  disto-buccal  extremity  of  stationary  anchor- 
ages and  near  the  occlusal  zone,  in  order  that  the  line  of  force  will  be  as  nearly 
parallel  as  possible  to  the  occlusal  plane,  to  reduce  the  extruding  tendency  of  the 
force  when  the  jaws  are  opened.  Its  extruding  action  is  one  of  the  main  objections 
to  this  principle  of  applying  force,  and  certainly  one  that  must  be  limited  in  its 
appHcation.     Especially  is  this  true  when  the  rubber  bands  are  attached  to  single 

Fii,.  7:5. 


^ 

I 

'   m  s^P 

1 
1 

molar  anchorages,  particularly  the  first  molars  with  no  retaining  arrangements, 
as  has  been  wrongly  advocated. 

Moreover,  the  disto-mesial  action  of  the  intermaxillary  force  is  an  indispen- 
sable adjunct  to  the  occipital  force  in  a  great  variety  of  conditions,  particularly 
where  the  buccal  teeth — both  upper  and  lower — have  drifted  forward  from  local 
causes.  It  is  also  one  of  the  most  important  adjuncts  for  the  reinforcement  of  weak 
molar  anchorages,  or  whenever  it  is  desirable  to  transfer  the  force  from  a  weak  point 
of  reaction  to  the  teeth  of  the  opposing  jaw.  It  is  also  indispensable  in  the  treatment 
of  many  conditions  which  heretofore  have  baffled  our  possibilities  of  applying  force. 

The  disto-mesial  intermaxillary  force  is  of  the  greatest  value  in  opening  spaces 
for  the  alignment  of  malerupted  cuspids  by  a  distal  movement  of  the  buccal  teeth 
which  have  drifted  forward  and  partially  or  wholly  closed  these  spaces. 


CHAPTER  XVI.     I  XT  ERM  AXILLARY   AXD  OCCIPITAL  FORCE 


129 


F[( 


^__^5-.  'I 


«© 


xO= 


-e» 


=e° 


Fig.  7.5. 


As  a  distal  move- 
ment of  buccal  teeth 
is  always  difficult,  the 
entire  force  of  the  in- 
termaxillary elastics 
may  be  directed  upon 
any  one  or  all  of  the 
buccal  teeth  through  the  medium  of  sliding  tubes  or  span-hooks.     See  Fig.  74. 

The  sliding  intermaxillary  hook  is  a  hook  soldered  to  a  short  section  of  an 
open  or  scam  tube  fur  quickly  attaching  the  intermaxillary  force  to  any  ap- 
pliance having  an  arch-bow.  This  sliding  hook  communicates  the  force  imme- 
diately to  any  band  attachment  on  the  cuspids  or  premolars  or  through  the 
medium  of  sliding  tubes  to  the  molars,  as  shown  in  3  and  5,  Fig.  141,  Chapter 
XXIV.  They  may  also  be  immovably  attached  to  the  arch-bow  with  soft 
solder. 

The  span-hooks  are  made  by  soldering  two  short  open  tubes  to  a  No.  19  or  18 
bar.  The  bar  is  bent  to  conform  to  the  line  of  the  arch-bow  and  to  span  any  inter- 
mediate attachment,  thus  communicating  the  force  directly  to  the  back  teeth. 

These  span-hooks  should  be  made  of  dif- 
ferent lengths  to  supply  every  immediate 
demand. 

Fig.  75  shows  two  conditions  in  which 
the  intermaxillary  long  span-hooks  are 
particularly  applicable.  In  both  these  cases 
the  malposition  of  the  cuspids  is  due  to 
premature  loss  of  deciduous  teeth  per- 
mitting the  buccal  teeth  to  drift  forward, 
demanding  a  distal  movement  of  these 
teeth  to  their  normal  occlusal  relations, 
with  no  labial  movement  of  the  incisors, 
thus  properly  opening  the  required  spaces 
for  the  eruption  and  alignment  of  the  cus- 
pids. In  the  upper  drawing,  the  required 
movement  of  the  buccal  teeth,  though 
sHght,  is  nevertheless  necessary,  because  of  the  erupting  second  molars,  which 
tend  to  increase  and  hold  the  malposition.  The  apparatus  shows  how  the  distal 
force  of  the  intermaxillary  elastics  may  be  directed  upon  the  molars,  while  their 
extruding  tendency  is  utilized  upon  the  nearly  erupted  cuspids. 

In  the  lower  drawing,  the  required  distal  movement  of  the  buccal  teeth  is  far 
greater;  consequently  the  tube  attachments  on  the  molars  are  short  and  loosely 
fitted  to  the  bow,  so  as  to  permit  free  distal  inclination  movement.  In  both  of  these 
cases,  the  distal  movement  of  the  premolars  is  accomplished  with  ligatures  to  the 


^ 


=i3» 


130  PART   IV.     TECIIMC   PRINCIPLES  OF   PRACTICE 

molars.  Hook  attachments  for  this  pm-posc  should  \)v  soldered  to  the  lingual  sur- 
faces of  the  bands  to  eqvialize  this  force. 

It  will  be  seen  that  this  possibility  of  transferring  the  motive  power  of  the 
elastics  from  points  of  application  to  distant  points  of  action,  presents  a  principle 
in  orthodontia  which  is  of  the  greatest  importance  in  a  variety  of  unique  applications 
of  force.  For  instance,  the  molar  teeth  of  one  jaw  as  an  anchorage  can  be  made  to 
move  the  opposing  molar  teeth  of  the  other  jaw  in  a  distal  or  mesial  direction.  It 
also  enables  moving  both  the  upper  and  lower  teeth  disto-mesially  by  a  reciprocat- 
ing action  of  the  force,  and  all  with  iia  niovcniciit  of  the  front  teeth. 

It  will  be  seen,  moreover,  with  a  little  thought,  that  the  sliding  span-hook 
permits  a  labio-lingual  reciprocating  action  of  the  elastic  force,  to  be  applied 
to  the  upper  and  lower  front  teeth,  the  one  to  be  moved  labially,  and  the  other 
lingually,  or  either  one  to  be  moved  separately. 

It  should  always  be  borne  in  mind,  as  elsewhere  stated,  that  the  distal  move- 
ment of  buccal  teeth  requires  far  more  force  than  their  mesial  movement,  because 
the  distal  bases  of  the  respective  arches,  at  whatever  age  the  operation  is  under- 
taken, will  be  found  to  rest  against  a  solid  foundation  of  alveolar  process  and  true 
bone,  or  against  erupting  teeth  which  are  forcibly  crowding  their  way  into  the  arch 
between  firmly  resisting  masses.  This  is  especially  true  of  lower  dentures  whose 
bases  are  composed  of  broad  and  solid  ridges  of  bone  supported  by  the  ascending 
rami.  It  was  through  quite  a  prevailing  belief  among  many  orthodontists,  which 
arose  about  fifteen  years  after  the  enthusiastic  general  awakening  to  the  extensive 
employment  of  intermaxillary  force,  that  all  disto-mesial  malocclusions  of  the 
dentures  of  Class  II  should  be  corrected  by  shifting  the  dentures  to  a  normal  occlu- 
sion with  this  force,  which  premised  that  no  teeth  should  ever  be  extracted  in  the 
correction  of  malocclusions.  Fifteen  years  of  practical  experience  along  these  lines 
has  shown  to  all  advanced  orthodontists  that  extensive — or  even  partially  exten- 
sive— distal  movement  of  buccal  teeth  ivhich  have  not  previously  drifted  forward 
from  the  loss  of  deciduous  or  permanent  teeth,  is  not  advisable;  and  especially  when  it 
involves  the  retrusion  of  an  entire  denture  to  correct  protrusions.  The  reason  for 
this  is  that  the  buccal  teeth,  uninfluenced  by  local  causes,  take  their  exact  inherited 
disto-mesial  positions  in  relation  to  the  jaws,  and  that  any  distal  movement  of  these 
teeth  will  almost  invariably  be  forced  back  to  their  former  positions  by  the  on- 
coming eruption  of  the  second  and  third  molars.  This  has  so  frequently  occurred 
even  after  operations  for  quite  young  children,  notwithstanding  the  perfect  inter- 
locking of  buccal  cusps,  in  forced  normal  occlusions,  that  attempts  to  correct  de- 
cided upper  or  lower  protrusions  in  this  way  are  rapidly  being  abandoned  for 
more  rational  and  scientific  methods  which  present  assurances  for  the  perfect 
correction  of  the  facial  outlines,  a  good  interdigitating  masticating  occlusion,  and 
permanency  of  retention.  A  distal  movement  of  molar  teeth,  however,  is  often  de- 
manded in  nearly  all  cases  in  which  they  have  been  allowed  to  drift  mesially  from 
local  causes,  and  for  the  correction  of  which  the  disto-mesial  action  of  the  elastics 


CHAPTER   XVI.     INTERMAXILLARY   AXD  OCCIPITAL  FORCE  131 

is  of  the  greatest  value.  A  favorable  method  for  this  purpose  is  to  employ  span- 
hooks,  as  described,  which  slide  upon  the  arch-bow  and  communicate  a  distal  inter- 
maxillary force  directly,  or  through  the  medium  of  sliding  tubes,  from  the  hooks  in 
the  vicinity  of  the  cuspids  to  which  the  elastics  are  attached,  to  hooks  at  the  distal 
end  of  lower  stationary  anchorages. 

In  whatever  direction  the  disto-mesial  movement,  the  apical  ends  of  the  roots 
are  rarely  if  ever  moved  with  the  application  of  intermaxillary  force — the  move- 
ment being  purely  that  of  inclination.  In  Chapter  X  are  pointed  out  by  Dr.  Cryer 
some  of  the  objections  and  dangers  in  a  considerable  distal  movement  of  the 
molars. 

In  the  contemplation  of  employing  the  intermaxillary  force  for  the  correction 
of  malocclusion  and  dento-facial  relations,  it  should  be  remembered  that  the  un- 
governed  action  of  the  elastics  will  in  all  probability  produce  a  far  greater  mesial 
movement  of  one  denture  than  a  distal  movement  of  the  other.  While  this  may 
perfectly  correct  the  occlusion,  the  dento-facial  outlines  may  be  left  in  cjuite  a  pro- 
truded state,  because  the  case  may  have  been  one  which  required  a  greater  distal 
movement  of  one  denture  than  a  mesial  movement  of  the  other.  And  this  would 
also  hold  true,  though  to  a  less  extent,  in  cases  where  an  eciually  reciprocal  movement 
of  both  dentures  is  demanded.  On  the  other  hand,  in  cases  where  the  mesial  move- 
ment should  be  greater,  as  in  slight  protrusions  of  the  upper  in  connection  with  a 
considerable  retrusion  of  the  lower,  as  described  in  Division  2  of  Class  II,  the  tm- 
restricted  action  of  the  intermaxillary  elastics  may  perfectly  perform  the  disto- 
mesial  correction  demanded,  and  without  recourse  to  the  exti-action  of  teeth. 

In  addition  to  restricting  or  preventing  the  movement  of  one  denture  by 
anchoring  the  teeth  together  in  phalanx,  there  is  a  variety  of  effective  methods  for 
accelerating  the  movement  of  the  other  denture,  or  rather  of  producing  the  greatest 
possible  movement  with  the  least  exhibition  of  force.  This  is  accomplished  prin- 
cipally in  two  ways:  First,  by  applying  the  force  throvigh  the  rnedium  of  movable 
attachments  at  the  occlusal  zone  with  its  advantage  toward  inclination'  movement, 
and  second,  by  applying  the  force,  first  to  the  most  distantly  located  teeth  in  line 
with  its  action,  and  then  to  the  next  teeth  in  line,  etc.,  until  all  have  been  moved. 
The  various  methods  and  technic  principles  will  be  found  fully  described  and  illus- 
trated in  detail  in  the  respective  classes  of  irregularities  where  the  intermaxillary 
force  is  applicable. 

Direct  Intermaxillary  Force. — Direct  intermaxillary  force  of  silk  ligatures 
to  aid  the  eruption  of  retarded  teeth  was  employed  in  the  latter  part  of  the  60's 
by  Dr.  Jerry  A.  Robinson,  of  Jackson,  Michigan. 

The  most  practical  form  of  direct  intermaxillary  force  is  that  which  was  in- 
troduced by  Dr.  E.  H.  Angle,  and  published  in  the  Dental  Cosmos,  September 
1891,  which  described  the  employment  of  this  method  for  correcting  impacted 
upper  cuspids  and  incisors.'  See  Fig.  273.  The  principal  use  which  the  author 
makes  of  this  form  of  force  is  in  the  correction  of  Open  and  Close-bite  Malocclu- 


132  PART   IV.     TI'TIIXIC   PKfXCf/'LES  OF   PRACTICE 

sions,  Bucco-lingual  Malocclusion  of  the  Molars,  and  Lateral  Malocclusion  of 
the  Dentures,  and  in  fact  all  ft)rms  of  Infra-occlusion  rc(iuirini;  extrusive  force,  a 
description  of  which  will  be  found  in  Specific  Methods  of  Regulating. 

In  Chapter  XXVIII,  is  fully  described  a  case  showing,  among  other  things,  the 
common  method  now  employed  for  correcting  open-bite  malocclusion  with  direct 
intermaxillary  force.  And,  in  Chapter  XXVII  is  described  and  illustrated  in  Figs. 
147,  148,  and  149,  one  of  the  common  intermaxillary  aids  in  the  correction  of  Lat- 
eral Malocclusion. 

An  important  discovery  in  the  application  of  direct  intermaxillary  force  on 
molar  teeth  is :  When  elastics  are  attached  to  hooks  on  the  buccal  surfaces  of  upper 
and  lower  molars  for  an  extrusive  movement,  the  molars  to  which  they  are  attached 
are  also  moved  lingually,  and  when  attached  to  the  lingual  surfaces,  they  are  also 
moved  bucally.  This  is  important  to  remember,  because  if  these  lingual  or  buccal 
movements  are  not  desired,  two  elastics  should  be  employed  attached  to  lingual 
and  buccal  hooks  to  equalize  this  force. 

This  bucco-lingual  movement  from  a  purely  extrusive  force  is  an  important  one, 
especially  in  those  cases  where  one  or  both  arches  have  been  expanded,  resulting  in 
an  inclination  buccal  movement,  causing  the  molars  to  occlude  upon  the  lingual 
cusps  alone.  While  the  expanding  appliances  are  at  work  or  in  place,  strong  direct 
intermaxillary  buccal  elastics  will  tend  to  move  the  roots  of  the  molar  teeth  buccall}^ 
In  other  words,  the  expanding  process  will  be  in  the  nature  of  a  bodily 
movement.  See  Fig  76.  If  this  or  some  other  provision  is  not  made 
for  a  bodily  expanding  movement,  the  malocclusion  of  the  cusps  will 
soon  drive  the  arches  back  to  their  former  malposition  after  the 
expanding  force  is  removed,  unless  firmly  retained.  See  Torsional 
Apparatus  for  bodily  expanding  movements.  Fig.  63. 

Fig.  77  shows  another  important  use  of  direct  intermaxillary 
elastics  in  those  cases  where  one  arch  has  been  expanded  with  the 
production  of  buccal  inclination  movement,  or  one  molar  has  been 
abnormally  expanded  or  moved  buccally  by  an  inadvertent  ex- 
panding force  of  an  alignment  or  expansion  arch-bow.  This  is 
easily  corrected  with  elastics  from  buccal  hooks  to  lingual  hooks  on 
opposing  molar  anchorages. 

Occipital  Force 

The  principal  force  with  which  the  Intermaxillary  is  an  important  auxiliary,  is 
the  Occipital,  and  as  these  two  forces,  in  the  author's  practice,  have  become  so  largely 
dependent  upon  each  other,  working  together  and  in  conjunction  with  dental  an- 
chorage forces,  he  deems  it  advisable  for  all  who  essay  the  regulation  of  teeth  to  thor- 
oughly acquaint  themselves  with  the  principles  and  latest  methods  of  its  application. 

The  Occipital  Force  was  among  the  first  to  be  used  for  the  regulation  of  teeth 
— the  early  practitioners  recognizing  the  advantage  of  locating  the  base  of  anchor- 


FiG.  77. 


CHAPTER   XVI.     INTERMAXILLARY  AND  OCCIPITAL  FORCE 


133 


age  completely  outside  of  the  immediate  field  of  action.  This  same  need  or  necessity 
was  the  "mother  of  the  invention"  of  the  intermaxillary  force.  As  means  develop 
for  applying  these  forces  in  a  scientific  and  skillful  manner,  they  will  be  considered 
more  and  more  among  the  indispensable  powers  for  the  regulation  of  teeth.  This 
can  only  be  accomplished  by  a  full  appreciation  of  dento-facial  relation^  re 

adoption  of  applicable  variations  in  methods  and  apparatus  which  wiL  lO 

prop-ir  corrective  movements  possible. 

Fig.  78. 


One  of  the  greatest  objections  and  drawbacks  to  the  more  general  adoption  of 
the  occipital  force  has  been  the  discomfort  and  irritation,  if  not  actual  pain,  which 
the  various  forms  of  headgear  apparatus  that  are  sold  on  the  market  give  to  sen- 
sitive patients,  and  which  so  frequently  causes  them  to  omit  wearing  it  a  sufficient 
portion  of  the  time  to  be  of  real  service. 

An  occipital  apparatus  should  be  one  that  can  be  perfectly  fitted  by  the  operator 
to  the  form  and  requirements  of  the  individual  patient,  with  no  prominent  or 


134  PART   IV.     TKCIINIC  PRINCIPLES  OF   PRACTICE 

projecting  portions  to  interfere  with  the  pillow  while  at  rest,  and  one  which  can  be 
easily  adjusted  by  the  patient  and  worn  with  the  least  possible  discomfort  during 
sleeping  and  waking  hours.  The  principal  direction  of  its  movement  is  upward  and 
backward,  with  a  tendency  toward  the  production  of  a  movement  when  applied 
to  the  teeth  that  is  frequently  demanded,  and  which  can  be  accomplished  in  no 
other  way. 

The  headcap  of  the  most  modern  apparatus,  well  shown  in  Fig.  78,  is  composed 
of  thin  metallic  ribbons  which  are  properly  shaped  and  provided  with  adjustable 
gears  for  fitting  it  to  the  size  of  the  head. 

It  can  be  adjusted  to  lie  smoothly  upon  the  surface,  and  place  the  force  where 
it  is  least  felt,  leaving  the  head  almost  entirely  free.  Silk  elastics  of  the  proper 
heft  are  used  for  the  motive  power.  They  are  buttoned  to  the  headcap  with  glove 
fastener  attachments,  and  pass  through  lock  swivel  loops  at  the  ends  of  the  dental 
bow  to  sliding  buckles  for  adjusting  the  amount  of  force.  All  metal  parts  are  highly 
nickel-plated. 

Bow  "A" — shown  in  the  lower  drawings — is  employed  to  exert  a  retruding 
and  intruding  force  upon  the  upper  labial  teeth;  bow"B,"  a  retruding  and  extruding 
force  upon  the  lower  labial  teeth;  and  bow  "C,"  a  distal  force  upon  the  buccal  teeth. 
Pi^-.  -,,  Fig.  79  shows  an  improved  form  of  post-rest  attach- 

ment, which  is  intended  to  prevent  the  sliding  move- 
ment which  may  cause  the  other  device  to  become  un- 
seated from  its  attachment  to  the  dental  bow. 

The  use  and  effectiveness  of  the  apparatus  depends 
largely  upon  the  manner  in  which  the  several  parts  are 
adjusted  and  fitted.  In  fitting  the  headcap,  the  encircling  band  should  rest  well 
back  upon  the  head  and  pass  just  above  the, ears;  the  two  bands  being  adjusted  to 
exert  an  even  pressure  throughout.  Carefully  bend  the  dental  retruding  bow  to 
conform  to  the  surfaces  over  which  it  rests,  nearly  touching  but  not  pressing 
against  the  lips  and  cheeks.  Its  final  relations  to  the  lips  are  adjusted  with  bow 
"A"  by  screwing  the  post-rest  in  or  out;  with  bow  "B,"  by  bending  the  posts;  and 
with  bow  "C,"  by  adjusting  the  arc  rests  to  properly  engage  with  the  attachments 
on  the  dental  bow. 

This  character  of  force  is  particularly  applicable  in  pronounced  cases  of  upper 
protrusions,  where  the  labial  teeth  are  in  a  decidedly  extruded  position  in  relation 
to  the  upper  lip,  and  in  connection  with  which  the  lower  incisors  often  strike  the 
gum  back  of  the  upper  incisors.  In  Close-bite  Malocclusions,  with  short  upper  lip 
and  prominent  teeth,  the  post-rest  bow  "A"  is  especially  adapted  for  this  movement. 

Another  irregularity  for  which  the  occipital  force  is  especially  applicable  is 
in  protrusion  of  the  lower  teeth  with  an  open-bite  malocclusion,  for  which  the  lower 
bow  "B"  will  often  be  found  exceedingly  effective.  The  possibility  which  is  now 
presented  for  applying  the  occipital  force  directly  to  the  lower  labial  teeth  in 
phalanx  through  the  medium  of  a  lower  dental  bow  as  an  aid  to  the  correction  of 


CHAPTER  XVI.     INTERMAXILLARY  AND  OCCIPITAL  FORCE  135 

Open-bite  malocclusions,  where  the  lower  jaw  and  teeth  are  protruded,  renders  the 
occipital  force  indispensable  in  the  author's  practice,  even  if  it  could  not  accom- 
plish another  object. 

One  of  the  most  modem  and  valuable  possibilities  of  the  occipital  apparatus 
is  that  which  now  enables  the  application  of  this  force  directly  to  the  buccal 
teeth  through  the  medium  of  the  bow  "C."  See  2  and  4  under  Fig.  141,  Chapter 
XXIV.  In  this  connection  it  is  especially  valuable  as  an  auxiliary  to  the  inter- 
maxillary force.  By  this  means,  as  is  fully  explained,  the  two  retrusive  forces  can 
act  upon  the  most  distal  upper  niolars,  or  all  of  the  buccal  teeth,  without  exerting 
any  force,  if  not  desired,  upon  the  labial  teeth.  In  fact,  the  incisor  teeth  can  be 
moved  labially  from  the  molar  anchorages  while  the  premolars  and  molars  are 
moved  distally  with  the  occipital  and  intermaxillary  forces  to  open  spaces  for  the 
eruption  of  crowded  cuspids. 

It  will  be  seen  that  the  entire  apparatus  is  so  constructed  in  its  several  parts 
that  it  may  be  easily  adjusted  by  the  operator  to  any  size  of  head,  and  thus  per- 
fectly fitted  to  each  individual  case.  If  proper  care  is  exercised  in  this  regard,  with 
the  usual  co-operation,  no  patient  will  object  to  wearing  it.  Many  patients  older 
than  twenty  years,  in  the  author's  practice,  are  wearing  the  apparatus  without  the 
slightest  complaint.  Younger  patients  of  course  will  always  adjust  themselves  to 
anj'thing  that  is  reasonable. 

The  chin-cap  is  made  of  fine  wire  gauze,  soldered  to  a  frame  of  proper  form 
and  provided  with  the  swivel  attachments  for  the  elastics.  When  fitted  to  the  chin, 
it  presents  a  ventilated  cap  which  exerts  an  even  and  comfortable  pressure. 

The  application  of  occipital  force  to  the  chin  for  the  bodily  retrusive  movement 
of  the  lower  jaw,  which  has  been  in  the  past  quite  a  popular  practice,  is  now  rarely 
considered  of  practical  advantage  after  the  years  of  childhood.  If  the  apparatus 
can  be  made  comfortable  for  the  little  ones  so  they  will  voluntarily  wear  it  with 
sufficient  persistence,  no  doubt  much  can  be  accomplished  in  this  way. 


PART  V 


Primary  Principles  of  Practice 


PRIMARY  PRINCIPLES  OF  PRACTICE 


CHAPTER   XVII 
IMPRESSIONS  AND   CASTS 

In  commencing  the  correction  of  an  irregularity,  good  impressions  should  be 
taken  of  the  dental  arches  separately,  and  a  labial  impression  of  the  front  teeth  with 
the  jaws  in  masticating  closure.  Perfect  plaster  casts  of  these  impressions  will  show 
the  exact  malposition  of  the  teeth ;  while  the  labial  cast  will  enable  an  adjustment  of 
the  upper  and  lower  casts  to  their  occlusal  relations. 

Absolute  duplication  of  the  parts,  as  required  for  artificial  dentures  which 
may  be  obtained  from  plaster  impressions,  is  rarely  if  ever  demanded.  In  fact, 
the  slight  difference  between  dental  casts  made  from  skillfully  taken  Modeling 
Compound  Impressions,  and  those  taken  with  plaster,  for  all  purposes  of  study 
and  use,  is  not  important;  nor  is  it  always  advisable  to  attempt  so  trying  an 
ordeal  as  a  plaster  impression  at  the  first  sitting  with  many  nervous  children  and 
youths.  If  the  occlusal  relations  of  the  teeth  were  a  competent  guide  for  their 
correction,  as  many  seem  to  think,  or  if  the  plaster  teeth  instead  of  the  natural 
teeth  were  used  for  taking  the  measurements  and  fitting  the  bands,  it  might 
then  be  different.  Moreover,  it  is  usually  advisable  to  have  a  number  of  casts 
of  each  case,  some  of  which  may  be  used  to  hold  the  measurements  and  bands 
in  place,  and  to  set  up  the  apparatus,  where  it  can  remain  undisplaced  until  the 
final  fitting  and  attachment  at  the  chair.  Again,  it  is  frequently  desirable  to 
take  impressions  for  casts  during  the  progress  of  the  case  with  appliances  on 
the  teeth,  or  at  times  when  the  apparatus  is  removed  for  radical  changes  of  force, 
and  during  times  when  the  sensitiveness  of  the  teeth  should  preclude  the  use 
of  plaster. 

In  the  author's  teaching,  competent  and  successful  diagnosis  to  determine 
the  movements  demanded,  can  be  accomplished  only  at  the  chair  where  the  natural 
occlusion  of  teeth,  and  the  influences  which  the  teeth  and  alveolar  processes  exert 
in  characterizing  the  facial  outlines,  may  be  carefully  and  intelligently  studied  in 
all  their  phases  of  malrelation.  The  author  wishes  it  to  be  understood,  however, 
that  he  has  no  objection  to  the  practice  of  taking  preliminary  plaster  impressions 
for  models  of  study — especially  by  those  who  cannot  or  do  not  obtain  perfect 
impressions  with  plastic  material — if  for  no  other  reason  than  it  tends  to  cultivate 
habits  of  nicety  and  exactitude  in  other  more  important  branches  which  pertain 
to  the  art  of  regulating  teeth. 

139 


Ill)  PART    v.     PRIMARY   PRiyCIPLES  OP   PRACTICE 

Vov  the  taking  of  Modeling  Compound  Impressions  of  the  teeth,  a  Tray  should 
be  selected  that  can  be  easily  introduced,  and  one  which  will  carry  the  compound 
well  over  the  labial  and  buccal  surfaces  of  the  teeth  and  gums.  Trays  shaped  and 
constructed  similar  to  certain  forms  of  the  Ash  and  Sons'  trays,  but  differing  in 
important  particulars  to  facilitate  introduction,  are  procurable,  and  in  sizes  adapted 

Fig.  so. 


to  the  mouths  of  children  as  well  as  to  adults.  In  Fig.  80,  it  will  be  noticed  that 
the  posterior  buccjl  extensions  are  considerably  lowered. 

Use  good  modeling  compound,  softened  in  hot  water  to  a  consistency  that  will 
take  a  sharp  imprint.  (The  author  prefers  the  white  compound  manufactured  by 
the  Dental  Mfg.  Co.  of  New  York  City.)  Warm  the  tray  and  place  only  a  sufifi- 
cient  amount  of  the  compound  in  it  to  take  the  complete  impression.  See  that  the 
impression  surface  is  smooth  and  free  from  creases.  Finally,  warm  the  surface  by 
passing  it  lightly  over  dry  heat. 

One  of  the  greatest  faults,  and  the  one  too  that  is  the  most  common,  is  to 
allow  the  surface  of  the  compound,  before  introduction,  to  become  cooler  and  con- 
sequently harder  than  the  body  of  the  compound  beneath,  whereas,  the  opposite 
consistency  shovild  be  the  endeavor.  The  compound  should  never  be  heated  to  the 
extent  of  stickiness,  or  allowed  to  lie  long  in  very  hot  water.  The  time  required  to 
place  it  in  the  warmed  cup,  shape  and  smooth  it,  will  cause  the  surface  to  become 
stififer  than  the  body.  If  it  is  introduced  in  this  condition,  it  cannot  make  a  sharp 
impression,  because  the  softer  compound  beneath  is  not  stifT  enough  to  press  the 
harder  surface  into  the  deep  sulci  to  sharply  define  the  gingival  borders. 

Give  the  compound  sufficient  time  for  the  entire  mass  to  lose  its  very  soft 
consistency  before  passing  it  lightly  over  a  small  Bunsen  Burner.  This  will  cause 
the  softer  overlying  portion  to  be  forced  to  place.  In  introducing  the  tray,  place 
it  so  as  to  leave  plenty  of  material  for  the  labial  portion  and  then  speedily  carry 
it  bodily  in  a  line  with  the  long  axes  of  the  teeth.  When  the  labial  surface  of  the 
compound  has  passed  the  gum  line,  in  the  process  of  forcing  it  to  place,  raise  the  lip 
and  press  the  compound  firmly  back  into  the  cup  and  against  the  gum  surfaces  to 
sharply  define  the  labio-gingival  borders.  Then,  and  not  until  then,  carry  the 
impression  fully  to  place,  and  hold  the  tray  perfectly  still  until  the  material  is 


CHAPTER  AT//.    IMPRESSIONS  AND  CASTS  141 

sufficiently  hard  to  remove  without  dragging.    The  time  may  be  hastened  by  spray- 
ing with  ice-water,  or  the  air  syringe. 

In  its  removal,  do  not  attempt  to  pull  the  impression  away  at  the  extreme 
end  of  the  handle,  but  grasp  the  tray  firmly  so  as  to  have  complete  control  of  its 
movement  exerting  a  slight  but  firm  tilting  motion  until  you  feel  the  first  indication 
that  the  impression  has  started  to  leave  its  imbedment;  then  with  gentle  force 
partially  allow  it  to  take  its  own  direction  of  movement  from  the  teeth.  If  it  does 
not  start  readily,  see  that  it  is  not  held  by  atmospheric  pressure.  Pull  the  tissues 
away  from  its  borders  and  allow  air  or  a  little  water  to  penetrate  beneath. 

Pic_  )^i_  After  obtaining  good  impressions  of  the  vipper  and 

lower  dentures,  take  an  occlusal  impression  of  the  labial 
teeth  as  follows :  See  that  the  teeth  are  closed  in  mas- 
ticating occlusion  and  admonish  the  patient  not  to 
open  them  dtiring  the  operation.  With  a  small  amount 
of  modeling  compound  placed  in  an  occlusal  tray 
(Fig.  81),  press  it  against  the  front  teeth  including 
the  cuspids  and  gums.  In  removal,  ask  the  patient  to 
open  the  mouth  and  then  gently  force  it  from  its  attach- 
ment to  the  upper  teeth. 

Duplicate  impressions  should  be  taken  at  another 
sitting  to  insure  against  imperfections  in  filling  or  breakage.  The  imperfect  ones 
are  used  for  working  models  during  the  entire  process  of  constructing  the  apparatus. 
The  filling  of  impressions  is  so  perfectly  described  in  textbooks  of  other  depart- 
ments that  it  is  not  necessary  to  speak  of  it  here.  In  the  teaching  of  this  branch, 
neatness  and  precision  in  shaping  the  casts  should  be  insisted  upon. 

If  the  base  lines  of  the  upper  and  lower  casts  are  trimmed  as  "a"  and  "b"  in 
Fig.  82,  and  parallel  to  the  occlusal  plane,  and  the  sides  and  front  at  right  angles 
to  the  base  from  the  extreme  borders  of  the  impression,  it  will  have  a  symmetrical 
appearance.  Overhanging  "Dutchman's  cap"  extensions  are  silly.  The  occlusal 
casts,  "c,"  may  be  trimmed  as  shown.  Do  not  varnish  the  casts  with  shellac.  If  a 
preservative  is  desired,  dip  them  in  hot  stearine.  The  name  and  age  of  the  patient 
and  date  of  taking  the  impression  should  be  written  plainly  on  each  of  the  casts. 

Facial  Impressions  and  Casts 

In  all  cases  of  dento-facial  deformities,  or  marked  imperfections  of  the  facial 
outlines,  which  are  caused  by  malpositions  of  the  teeth  and  jaws,  facial  plaster 
casts,  from  plaster  impressions  which  exactly  represent  the  natural  contours,  are 
far  superior  to  facial  photographs  for  all  purposes  of  study  and  comparison  of  the 
features  at  different  stages  of  the  operation,  because  they  permit  an  examination  of 
every  outline  from  different  angles  of  observation. 

If  a  plaster  cast  of  the  physiognomy  is  indicated,  the  operation  should  be 
deferred  until  you  have  gained  the  full  confidence  and  friendliness  of  the  patient. 


142 


PART    V.     PRIMARY   PRLXCIPLKS  OP  PRACTICE 


Without  this,  all  operations  which  reqiiirc  for  tlieir  success  the  full  co-operation 
of  the  patient  should  not  be  undertaken. 

Say  nothing  to  young  patients  upon  the  suljject  of  an  impression  of  the  face 
mitil  you  are  all  ready  to  take  it.  Then  treat  it  as  a  matter  of  course  and  with 
no  apparent  thought  that  there  will  be  any  objection.  Explain  what  you  are  going 
to  do  and  just  how  they  are  going  to  help  you;  tell  them  it  will  not  give  the  slightest 

Fk;.  82. 


pain,  and  will  only  take  about  ten  minutes.  Exclude  parents  and  friends  from  the 
room,  or  at  least  from  standing  by  the  chair,  and  have  no  one  looking  on  within  their 
sight  after  you  commence  with  the  plaster.  If  the  patient  is  young,  do  not  let  him 
see  that  this  is  an  intentional  ostracism.  You  know  the  effect  which  the  conscious- 
ness of  some  one  gazing  into  your  face  would  have  upon  your  control  of  the  facial 
muscles  during  a  long  sitting  for  a  photograph,  and  how  this  would  be  increased  if  you 
were  allowed  to  "catch  the  eye"  from  time  to  time  of  an  acquaintance  or  relative. 
Repose  the  patient  well  inclined  in  an  easy  position  with  the  face  turned  from 
you,  and  make  all  preliminary  arrangements  with  the  least  possible  appearance  of 
preparing  for  a  difficult,  or  even  a  particular  operation. 


CHAPTER  XVII.     f.UPRESSIOXS  AXD  CASTS  143 

Have  ready  a  small  quantity  of  white  perfumed  vaseline  in  a  small  thin  glass, 
placed  in  a  clean  white  bowl  of  warm  water,  to  partially  liciuidize  the  vaseline. 
Use  an  inch  wide  fiat  camel's  hair  brush,  to  apply  the  vaseline  rapidly,  and  be  sure 
that  every  part  is  gone  over  where  you  intend  to  lay  the  plaster.  If  the  eyebrows 
are  heavy,  use  the  vaseline  more  or  less  congealed ;  nor  should  any  of  the  vaseline 
be  hot  or  in  a  fully  liquid  state.  Do  not  feel  obliged  to  brush  the  hair  away  from 
the  forehead  or  ears  to  an  unnatural  position.  It  adds  to  the  artistic  effect  of  the 
model  to  show  a  portion  of  the  hair  naturally  aiTanged  and  even  partially  covering 
the  ear. 

Commence  with  the  vaseline  upon  the  cheek,  and  then  the  mouth,  lips,  and 
teeth — if  the  latter  are  exposed.  Assure  your  patient  that  the  vaseline,  and  also 
the  plaster  which  is  to  follow  it,  is  perfectly  clean,  that  none  of  it  will  drop  into  the 
mouth  even  though  the  lips  arc  slightly  open;  and  ask  him  to  avoid  if  possible  any 
movement  of  the  lips  while  the  plaster  is  being  laid  over  the  mouth,  as  it  will  spoil 
the  natural  pose  which  you  are  striving  to  catch.  The  involuntary  tendency  of  the 
muscles  to  tightly  close  the  lips  to  keep  out  offensive  substances  will  mar  the  habit- 
ual pose  of  the  lips  and  chin.  This  may  be  easily  overcome,  even  with  very  nervous 
patients,  with  a  little  patience  and  kindly  persistence  in  applying  the  vaseline, 
which  they  soon  realize  is  in  nowise  disagreeable,  and  that  the  same  will  be  true  of 
the  plaster. 

In  carrying  the  vaseline  well  up  under  the  eye,  ask  the  patient  to  look  upward 
and  tell  him  that  when  the  plaster  is  being  put  on  at  that  point  to  maintain  that 
position  for  a  few  minutes,  without  winking,  to  prevent  the  lashes  of  the  upper 
lid  from  becoming  smeared  with  it  while  soft — that  it  will  soon  be  hard  and  free 
from  this  danger. 

Place  a  small  pledget  of  cotton  in  the  ear,  and  work  the  vaseline  well  into 
the  surrounding  depressions  and  out  over  the  rim.  You  will  now  arrange  the  hair, 
if  you  have  not  previously  done  so,  and  vaseline  it  and  the  eyebrows  as  described. 
Ask  the  patient  to  close  the  eyes,  and  lubricate  the  surface  of  the  upper  lid  down 
to  the  lashes;  then  the  depression  surrounding  the  canthus — down  over  the  nose 
to  the  very  borders  of  the  nostrils;  and  join  that  portion  of  the  vaseline  which  you 
first  laid  on.  Let  the  operation  be  thorough,  even  to  going  back  over  surfaces 
that  do  not  seem  to  be  well  lubricated,  as  upon  this  depends  the  ease  of  removing 
the  impression.  In  fact,  the  titillating  effect  of  the  brush  is  good  discipline  to  the 
muscles  for  acquiring  immovability  during  the  application  of  the  plaster. 

If  it  is  to  be  a  cast  of  the  profile  only,  the  vaseline  should  stop  just  beyond 
the  border  of  the  median  line  of  the  face.  If  a  front  view  impression  is  intended  to 
be  taken  in  one  piece,  its  distal  borders  should  not  extend  beyond  the  malar  prom- 
inences, as  otherwise  it  will  be  difficult  to  remove  without  breaking.  However, 
an  impression  can  be  taken  in  any  number  of  sections  by  covering  the  borders 
of  the  plaster  where  you  decide  to  stop  with  vaseline  before  proceeding  w^ith  the 
next  section.     These  sections  can  then  be  removed  separately  and  fitted  together 


144  /MA'7-    r.     rKIMAKV    /'RfXC/PLES  OF   PRACTICE 

bc'ldri'  fillin>,f.  In  this  way,  the  whole  face,  head,  and  neck  can  be  taken;  although 
such  an  extensive  attemj^t  is  not  advisalile  until  you  have  had  eonsideral.)le  ex- 
perience in  the  work. 

Above  all  things,  do  not  admonish  the  patient  about  laughing  or  smiling,  before 
or  (luring  the  process  of  putting  on  the  vaseline  or  plaster.  If  you  see  such  a  ten- 
dency, pay  no  attention  to  it,  not  even  when  in  laying  the  plaster  over  the  mouth 
you  fear  it  may  spoil  the  impression.  If  he  is  at  once  made  to  believe  that  you  are 
seriously  unconscious  of  his  emotions,  by  some  commonplace  remark  which  you 
may  make  to  yotir  assistant  about  the  weather,  or  of  something  you  pretend  to  see 
out  of  the  window,  the  danger  will  usually  be  averted  by  leading  his  mind  into  an- 
other channel,  with  an  immediate  subsidence  of  the  smile  before  the  plaster  has  be- 
come sufficiently  hard  to  be  aftected  by  it. 

On  occasions,  it  has  been  observed  by  the  slight  quivering  of  the  lips  and 
moisture  in  the  eyes  of  little  ones,  that  the  opposite  tendency  was  uppermost. 
This  should  be  treated  in  the  same  way,  perhaps  with  some  cheerful  confident  re- 
mark to  your  assistant  complimenting  the  patient's  fine  behavior,  and  that  it  will 
be  all  over  in  a  few  minutes,  etc.,  bvit  by  no  means  with  a  word  or  action  of  sym- 
pathy unless  you  wish  them  to  break  down.  In  almost  every  case,  out  of  the  hun- 
dreds of  facial  impressions  the  author  has  taken,  even  little  ones  who  at  first 
trembled  at  the  sight  of  the  dental  chair,  will  become  seriously  and  cheerfully 
interested,  because  of  the  fact  that  they  have  been  made  to  feel  they  are  in  safe 
hands  and  that  everything  will  transpire  exactly  as  told  to  them. 

In  a  serious  operation  of  any  kind,  children  sh(_)uld  never  be  treated  as  babies  re- 
quiring expressions  of  sympathy.  Treat  them  rather  as  individuals  of  character  who 
possess  self-control,  pkick,  and  bravery.  They  possess  the  canine  instinct  of  knowing 
who  are  their  friends,  though  they  will  rarely  give  you  their  whole  confidence  in 
the  presence  of  a  loving  and  sympathetic  mother,  who  unfortimately  will  sometimes 
imagine  it  helps  her  children  to  stand  by  the  chair  and  hold  their  hands,  etc. 

The  plaster  should  be  of  a  fine  but  slow  setting  quality.  Mix  with  a  slight 
excess  of  water  that  will  not  chill,  and  stir  thoroughly  to  a  smooth,  clinging  con- 
sistency, which  may  be  handled  easily  with  a  spatula  and  will  stay  in  place  on 
inclined  surfaces. 

Use  for  the  main  work  a  spatula  that  is  full  width  but  about  two-thirds  the 
usual  length.  This  can  be  made  from  an  ordinary  plaster  spatula.  A  narrow 
spatula  should  be  at  hand  when  needed  for  certain  deep  places,  or  where  small 
cjuantities  of  plaster  with  delicacy  of  manipulation  is  required. 

Everything  being  ready,  call  for  the  first  bowl  of  plaster.  Hold  it  in  the  left 
hand  just  beneath  the  face  with  the  arm  over  the  head,  and  with  the  spatula  lay 
the  plaster  first  upon  the  cheek  and  approach  the  area  of  the  mouth,  extending 
it  beyond  the  median  line,  and  from  the  wings  and  septum  of  the  nose  to  a  point 
well  beneath  the  chin.  Then  cover  the  cheek  to  the  border  of  the  lower  lid  while 
the  patient  is  looking  steadily  toward  the  ceiling. 


CHAPTER  XV 11.    IMPRESSIONS  AND  CASTS  145 

The  thickness  of  the  plaster  should  at  first  be  only  sufficient  for  the  impression. 
You  will  reinforce  it  finally  at  the  weaker  points  for  strength,  when  it  is  not  so 
important  to  avoid  the  dragging  force  of  its  heft. 

In  carrying  the  plaster  along  from  the  borders  of  each  spatulaful,  give  a  slight 
shaking  or  trembling  motion  to  the  spatula,  to  tease  the  plaster  smoothly  over  the 
surface  and  down  into  deep  depressions,  as  between  lips,  around  exposed  teeth,  etc. 

The  plaster  should  be  handled  with  skill  and  delicacy  of  manipulation,  with 
no  abrupt  or  awkward  motion,  as  for  instance,  striking  the  skin  with  the  spatula — 
that  would  cause  pain  or  even  surprise  and  a  lack  of  perfect  relinquishment. 

The  same  is  true  in  an  ethical  sense  in  regard  to  all  your  conversation,  words  of 
warning,  direction,  etc.  Inspire  your  patient  with  a  kind,  cheerful,  and  con- 
fident atmosphere.  Never  speak  loudly  or  peremptorily  to  your  assistants,  as 
calling  to  "hurry  up  with  that  plaster,"  etc.,  or  in  unkind  criticism,  even  though 
you  have  the  best  of  reasons,  and  things  seem  to  be  going  all  wrong;  for  the  little 
ones,  like  the  "gallery  gods,"  are  quick  to  note  a  discordant  strain,  and  it  may 
come  at  a  tinie  when  they  are  all  but  ready  to  break  down  in  one  way  or  the  other, 
and  at  the  crucial  moment  when  the  plaster  has  commenced  to  set  over  the  mouth. 
Here  the  slightest  movement  of  the  muscles  indicative  of  the  emotions  will  destroy 
the  really  important  part  of  the  impression. 

The  advice  which  was  given  in  explaining  the  lubricating  process,  relative 
to  the  ethical  management  of  the  patient,  will  be  especially  important  while  you 
are  striving  to  safely  pass  the  critical  point  around  the  movith ;  after  this  there  is 
usually  little  occasion  for  anxiety. 

Follow  the  same  course  with  the  plaster  that  was  described  in  laying  on  the  vase- 
line. The  first  mix  of  plaster  will  usually  cover  the  mouth,  cheek,  ear,  hair,  and  eye- 
brows, providing  that  you  work  rapidly ;  then  you  can  finish  with  the  second  mix ; 
although  three  and  even  four  mixes  are  sometimes  necessary  when  the  plaster  sets 
rapidly.  The  last  and  thicker  portion  of  the  first  mix  should  be  used  over  the  hair 
and  eyebrows,  as  it  is  not  so  liable  to  cling  upon  removal.  To  do  this,  it  is  often  neces- 
sary to  skip  the  ear,  which  should  then  be  covered  with  the  first  of  the  second  mix. 
As  soon  as  the  plaster  commences  to  thicken,  call  for  another  bowl,  continuing  with 
the  one  in  hand  until  it  has  become  too  thickened  to  spread  well.  If  an  extra  mix  is 
required  for  finishing  the  impression  of  the  nose — which  shovild  be  with  plaster  that 
flows  readily  with  a  slight  shaking  motion — have  a  small  quantity  of  potassium 
sulphate  mixed  with  the  water,  then  the  remaining  portion  of  the  plaster  will  serve 
to  reinforce  the  impression,  and  you  will  not  be  obliged  to  wait  so  long  for  it  to  set. 

It  reciuires  considerable  delicacy  of  manipulation  to  work  the  plaster  over 
the  upper  eyelid  till  it  nearly  touches  the  lashes,  and  around  the  borders  of  the 
canthus  also  at  the  end  of  the  nose  down  over  the  septum  and  to  the  very  borders 
of  the  nostril,  without  closing  the  opening  so  as  to  obstruct  breathing.  Do  not 
attempt  to  put  an>'thing  into  the  nose,  such  as  quills,  etc.,  for  this  purpose,  it 
only  serves  to  annoy  the  patient  and  is  never  necessary. 


146  PART    V.     PRIMARY   PRINCIPLES  OF   PRACTICE 

After  waiting  until  the  plaster  is  hard,  place  the  fingers  under  the  edge  of  the 
mesial  Ijorder  of  the  impression  and  lift  with  a  gentle  force,  working  it  slightly  with 
a  lateral  movement.  I )( >  not  use  force  as  you  would  in  removing  a  plaster  impression 
from  the  mouth.  It  will  soon  yield  if  the  lubrication  has  been  thoroughly  per- 
formed. If  it  clings  to  the  eyebrows  or  hair,  as  soon  as  you  have  raised  it  suffi- 
ciently to  pass  the  fingers  or  a  rubber  spatula  beneath,  you  will  be  able  to  feel  the 
clinging  hair  or  hairs,  and  by  pressing  downward  toward  the  skin,  they  can  be 
gently  dislodged  from  the  plaster.    This  part  of  the  operation  is  usually  performed 

by  the  assistant. 

Fro.  s:j. 


The  above  illustration  shows  frtjm  left  to  right,  the  outside  and  inside  of  the  impression,  and  the  final  facial  cast 

made  from  the  impression. 

Unhinge  it  slowly  and  carefully  from  the  ear,  working  out  the  clinging  portions 
of  the  rim  or  hair  with  the  finger.  The  pledget  of  cotton  generally  comes  away  with 
the  impression,  where  it  is  allowed  to  remain  during  the  filling  process,  and  if 
waxed  and  shaped  to  the  proper  form  it  serves  to  represent  the  external  meatus. 

In  preparing  the  impression  for  filling,  the  eye  and  nostril  holes  are  covered 
with  wax  (externally)  in  such  a  manner  as  to  leave  the  borders  well  defined;  this 
will  allow  for  an  excess  of  plaster  at  these  points  that  can  be  finished  by  carving. 
Varnish  with  a  thin  coat  of  shellac,  followed  with  sandarac,  and  then  thoroughly 
soak  the  impression  in  water  just  before  filling.  In  the  process  of  filling,  imbed 
two  corks  in  the  back  of  the  cast  so  as  to  raise  it  to  the  proper  angle,  if  desired  to 
fasten  it  to  a  board  with  screws. 

Before  separating,  soak  it  thoroughly  in  warm  water  and  dip  it  occasionally 
while  chipping  oft"  the  impression.  In  other  particulars  follow  the  same  rules  as 
in  separating  plaster  impressions  of  partial  dentures.  In  carving  the  borders  of 
the  closed  eyelid  and  open  nostril,  continue  the  curves  of  the  natural  surfaces. 
This  will  cause  the  greater  prominence  of  the  upper  eyelid  to  rest  upon  the  lower, 
and  carry  the  lines  of  the  nostril  to  the  more  abrupt  curve  which  enters  the  orifice. 

When  the  cast  becomes  soiled  at  any  time  later,  a  thin  coat  of  light  pink  cal- 
cimine will  give  it  an  agreeable  flesh  color.  This  can  be  renewed  at  any  time  by 
washing  oft'  the  previovis  coat. 


CHAPTER   XVUl 

PRIMARY   PRINCIPLES   AND   TECHNICS   IN   THE   CONSTRUCTION 

OF    BANDS 

Separating  the  Teeth.  —  In  practice,  when  the  character  of  any  irregularity 
and  the  appropriate  apparatus  for  its  correction  is  determined,  the  measurements 
of  the  natural  teeth  for  the  required  bands  should  be  taken.  As  a  preliminary  step, 
see  that  the  teeth  are  sufficiently  separated.  For  the  purpose  alone  of  taking  the 
measurements,  the  operation  of  separating  should  never  be  performed,  unless 
absolutely  necessary,  as  the  separators  usually  require  to  be  left  between  the  teeth 
twenty-four  hotirs,  and  with  some  nervous  and  sensitive  patients  this  is  exceed- 
ingly annoying,  if  not  painful. 

Separating  Tape. — In  operations  for  youths,  if  it  is  necessary 
to  first  separate  the  teeth  slightly  in  order  to  force  the  bands  be- 
tween them  for  the  measurements,  use  the  thinnest  and  narrowest 
flax  waxed  tape  that  will  stay  in  place  without  dislodgment. 
Thus,  by  a  gradual  approach,  the  severer  conditions  that  may  be 
found  necessary  with  a  greater  separation  will  be  withstood  later 
in  the  operation  without  a  murmur. 

Waxed  tape  is  made  in  three  widths,  Nos.  1,  2,  and  3,  Fig.  84. 
^.    „  Where  space  is  demanded  for  taking  the  measurements,  etc.,  at 

separating  lape.  ^  ^ 

first  use  the  No.  1,  and  if  necessary,  follow  it  with  No.  2,  or  No.  3, 
folded  with  one  edge  slightly  projecting  to  facilitate  introductions.  Where  the  No. 
1  has  remained  between  the  teeth  for  several  hours,  the  folded  tapes  can  be  easily 
introduced,  and  the  teeth  will  speedily  respond. 

Between  back  teeth  where  the  thicker  interproximate  portions  of  double-band 
anchorage  or  adjoining  bands  of  completed  appliances  are  to  be  attached,  the  folded 
tapes,  finally,  will  always  be  necessary.  With  older  patients  it  may  at  times  be 
found  advisable,  especially  when  the  contact  point  is  near  or  at  the  occlusal  sur- 
faces, to  tie  floss  silk,  or  twist,  around  the  contact  point  with  the  knot  in  the  inter- 
proximate space.  A  few  fibers  of  cotton  placed  in  the  loop  may  in  this  way  be  drawn 
in  and  held  firmly  between  the  teeth. 

Method  of  Introducing  Tape. — In  insei'ting  the  tape,  hold  the  roll  in  one 
hand  with  a  sufficient  length  unrolled  to  be  grasped  firmly  and  extended  tautly  with 
the  other;  then,  with  the  forefingers  on  the  occlusal  edge  of  the  tape  near  the  teeth, 
press  the  gingival  edge  into  the  space  with  a  sawing  motion. 

When  the  separating  tape  is  inserted  between  the  teeth,  it  is  important  that 
it  be  cut  off  closely  within  the  interproximate  spaces  in  order  that  no  projecting 

147 


148 


PART    V.     PRIMARY  PRINCIPLES  UP  PRACTICE 


ends  or  fraying  threads  are  left  to  act  as  sources  of  irritation  or  inducements  to  the 
removal  of  the  separators  during  the  twenty-four  or  forty-eight  hours  they  are 
required  to  remain  between  the  teeth.  For  this  purpose,  scissors  should  be  used 
with  blades  that  are  short,  sufficiently  narrow,  and  properly  curved  to  enable  the 
operator  to  place  the  pointed  ends  on  either  side  of  the  tape  as  it  emerges  from  its 
lodgment,  and  cut  it  cleanly  to  the  shortest  possible  length.  A  fine  grade  of  curved 
manicure  scissors  may  be  used  whose  blades  have  been  ground  to  the  narrowest  limit 
consistent  with  strength.    Tape  scissors  that  are  especially  constructed  for  the  pur- 


FiG.  S.'). 


Fig.  S(5. 


pose,  as  shown  in  Fig.  85,  will  be  found  convenient,  especially  in  reaching  the  most 
distal  requirements  of  the  back  teeth. 

When  the  separating  tapes  have  been  cut  off  as  closely  as  they  should  be  in 
this  manner,  the  difficulty  of  removing  them  is  increased,  and  it  is  often  impossible 

with  ordinary 
tweezers  and 
pliers.  Fig.  86 
shows  specially 
constructed  Tape 

Pliers  whose  beaks  are  strong  and  pointed  with  interdigitating  serrations  calculated 
to  penetrate  the  interproximate  space  and  firmly  grasp  the  tape. 
Fig.  s7.  Orthodontia   Bands. — Band   Material,    Fig.   87,   is  made  in  three 

widths, — narrow,  meditim,  and  wide, — and  in  thicknesses  which  range 
from  .003"  to  .006". 

The  consistent  place  for  the  joints  of  front  bands  requiring  attach- 
ments is  on  the  labial  surfaces,  not  only  because  of  the  greater  ease 
and  more  assured  accuracy  in  taking  the  band  measurements,  but  mainly  because 
the  finished  bands  take  a  more  natural  and  stable  position  in  relation  to  the  crowns. 
It  will  be  noticed  that  when  a  piece  of  straight  band  material  is  passed  around  an 
upper  central  incisor,  for  instance,  and  drawn  or  pressed  forward  so  that  its  middle 
portion  lies  flat  against  the  lingual  surface  of  the  tooth,  for  the  purpose  of  making 
the  joint  in  front,  its  free  ends  incline  upward  toward  the  gum.  Consequently, 
when  the  ends  are  properly  pinched  for  the  joints  and  soldered,  the  location  of  the 
labial  portion  is  considerably  more  root-wise  than  the  lingual,  and  therefore  more 


Band  Material. 


CHAPTER   XVIII.     CONSTRUCTION   OF   BANDS 


149 


Fig.  88. 


a 


in  accord  with  the  mean  gingival  border  hnes  of  gum  and  enameh  See  "a,"  Fig. 
88.  This  is  true  to  a  more  or  less  extent  of  all  the  front  teeth.  On  the  other  hand, 
when  straight  band  strips  are  passed  around  these  teeth  in  the  opposite  direction 
for  lingual  joints,  and  pressed  evenly  against  the  labial  surfaces,  the  bands  will 

take  the  opposite  inclination  in  relation  to 
the  gingival  zone,  with  the  frequent  necessity, 
when  taking  the  measurements,  of  forcing  the 
edges  into  the  lingual  and  interproximate  gin- 
givae in  order  to  secure  sufificient  gingival 
nearness  in  front.  This  is  important  in  most 
instances,  because  in  the  application  of  all 
lingvio-labial  and  linguo-buccal  forces  which 
are  not  intended  for  inclination  or  "tipping" 
movements,  whether  direct  or  torsional,  the  attachments  to  the  bands  should 
always  be  placed  as  near  the  gingival  borders  as  admissible,  if  one  wishes  to  obtain 
the  greatest  mechanical  advantages  toward  moving  the  teeth  bodily  or  semi- 
bodily.    See  "b,"  Fig.  88. 

Among  the  minor  advantages,  when  the  rib  of  the  band  joint  after  soldering 
is  trimmed  to  project  about  a  32nd  of  an  inch,  and  is  then  mashed  flat  and  the  sur- 
face contoured  with  fitting  pliers  for  the  front  teeth,  and  contour  pliers  for  the 
buccal  teeth,  so  that  they  exactly  fit  the  labial  and  buccal  contours  of  the  crowns; 
and  finally  when  the  joint  and  adjoining  surfaces  are  reinforced  with  No.  18  gold 
solder,  or  No.  2  silver  solder — as  will  be  explained — there  is  no  other  method 
that  aft'ords  a  greater  degree  of  strength,  perfection  of  fitting,  and  permanency  of 
attachment  to  the  tooth,  or  one  that  is  superior  in  artistic  eft'ect;  particularly 
because  this  method  of  reinforcing  the  joint  and  labial  surfaces  with  solder  nearly 
obscures  the  joint  while  its  strength  permits  narrowing  the  front  of  the  labial  bands 
to  the  minimum  width,  especially  for  all  operations  in  aligning  the  teeth  with  the 
resilient  forces  of  light  arch-bows. 

Dr.  Angle's  insistence  that  the  joints  of  the  front  bands  should  always  be 
located  on  the  lingual  surfaces  may  be  partly  due  to  the  fact  that  there  is  no  other 

way  of  placing  on  the  market  his 
modem  appliances  with  their  difficult 
technic.  And  it  may  be  also  for  the 
same  reason  that  he  insists  upon 
those  ctmibersome,  irritating  and 
unsanitary  lingual  clamp-band  joints 
for  molar  anchorages. 

For   taking   the    band   measure- 
ments, the  Banding  Plier  shown  in 
Fig.  89  is  recommended.     The  extreme  ends  of  the  beaks  are  shaped  to  obtain  three 
grasping  positions  of  the  plier,  "a,"  "b,"  and  "c,"  Fig.  90,  which  will  be  found  con- 


FiG.  89. 


150  PART    r.     PRIMARY    I'RISCI i'lJ'lS  OF   PRACTICE 

venient  for  the  different  angles  in  which  the  pher  must  be  held  in  crimping  the 

joints  of  the  bands  for  different  teeth.     By  placing  the  sharpened  edges  back 

from  the  crimping  points  of  the  band,  while  pressing  them  firmly  against  the 

teeth,  thev  will  bite  into  the  surfaces, 
Fir,,  on.  -  .  . 

and  thus  enable  drawnig  the  band  tightly 

around  the  tooth  in  the  act  of  bringing 

the  beaks  together  for  the  joint.     One 

of  the  important  features  of  this  plier 

is  the  open  and  rounded  inner  surfaces  of  the  shanks  of  the  beaks,  which  prevents 

pinching  tlie  lips  when  the  crimping  edges  are  brought  together. 

The  Band  Material,  Fig.  87,  should  be  cut  into  lengths  no  longer  than  re- 
quired to  facilitate  adjustment.  If  students  commence  with  the  incisor  bands, 
they  will  have  acquired  a  certain  degree  of  training  for  the  more  difficult  molar 
measurements. 

Grasp  the  ends  of  the  looped  piece  of  banding  material  between  thumb  and 
fingers  of  one  hand,  and  force  the  loop  between  the  proximal  surfaces  of  the  teeth 
with  the  other,  and  while  drawing  it  firmly  to  place,  bend  it  to  fit  the  lingual  in- 
equalities of  the  tooth  in  order  to  give  proper  direction  to  the  joint  ends.  Still 
holding  the  ends  between  finger  and  thumb,  place  the  open  jaws  of  the  plier  with 
ends  resting  back  upon  the  band  on  either  side  of  the  joint.  Pressing  the  band 
against  the  tooth,  bring  the  jaws  firmly  together,  and  move  the  pliers  slightly  to 
and  fro  to  sharply  bend  the  joint  marking. 

Carefully  remove  each  band  as  it  is  measured  to  avoid  obliterating  the  mark, 
and  place  it  in  the  proper  position  on  a  form,  or  on  its  proper  tooth  of  the  working 
model — the  teeth  of  which  have  been  sawed  apart  for  this  purpose.  Proceed  in  a 
similar  manner  with  the  cuspids  and  premolars.  Working  forms  are  easily  made 
with  thin  pieces  of  wood  into  which  short  brads  are  driven  in  the  positions  and  align- 
ment of  the  teeth  in  the  dental  arch. 

Molar  Measurements. — The  molar  bands  being  much  thicker  and  more  rigid 
are  more  difficult  to  adjust  and  perfectly  fit;  considerable  force,  often  with  the 
plier,  is  required  to  force  the  band  between  the  teeth.  If  the  spaces  are  insufficient, 
insert  the  wider  folded  tape.  Fifteen  or  twenty  minutes  will  usually  be  sufficient — 
the  teeth  having  become  slightly  loosened  with  the  first  separation. 

When  the  band  material  for  a  molar  band  is  placed,  grasp  the  distal  end  with 
the  plier  and  bring  it  firmly  forward,  sharply  bending  it  at  about  the  middle  of  the 
buccal  surface.  Then  grasp  the  mesial  end,  and  carry  it  back  with  the  sharp  bend 
at  a  point  that  will  leave  the  two  joint  surfaces  about  ys  of  an  inch  apart. 

Now  include  both  ends  in  the  grasp  of  the  plier,  and  while  forcing  the  beaks 
against  the  tooth,  bring  them  firaily  together,  as  described  for  the  incisors.  If 
the  bands  are  wide  and  thick,  it  may  be  well  to  re-grasp — starting  back  from  the 
joint — and  repeat  the  movement.  In  fact,  after  a  band  is  soldered  and  found 
to  be  too  large,  a  tuck  can  be  taken  up  in  it  in  this  way,  showing  the  utility  of  the 


CHAPTER  XVIII.    CONSTRUCTION  OF  BANDS 


151 


movement  for  drawing  the  band  to  a  perfect  fitting.     Quite  frequently,  in  taking 

the  measurements  for  second  molar  bands,  it  will  be  found  more  convenient  to 

pinch  the  joint  on  the  lingual  surfaces. 

Measurements  for  Partially  Erupted  Cuspids. — A  perfect  fitting  band  can  be 

made  for  a  cuspid  not  fully  erupted  without  causing  more  than  a  slight  pain,  if  the 

measuring  process  is  managed  properly.     Loosen  the  surrounding  gum  covering 

the  enamel,  which  will  be  fotind  to  have  a  slight  attachment,  then  carefully  work 

the  loop  of  the  band,  held  as  described,  beneath  the  lingual  border  of  the  gvmi. 

Sometimes  it  can  be  passed  under  the  linguo-gingival  border  the  full  width  of  the 

band  without  even  drawing  blood.     In  this  position  the  ends  on  the  labial  aspect 

may  be  pinched  for  the  joint. 

Soldering  Bands 

Preparatory  to  soldering  the  joints,  the  ends  of  the  bands  should  be  cut  off 
to  about  /4  of  an  inch,  then  placed  in  the  grasp  of  the  Band   Burnishing   Plier 

Fig.  91. 


(Fig.  91),  or  a  bkmt  square-nosed  plier,  and  burnished  toward  the  joint  on  the  in- 
side of  the  band  so  as  to  carry  the  ends  deeply  between  the  jaws  to  form  a  perfectly 
united  joint  when  soldered. 

Before  placing  the  band  in  the  grasp  of  the  Solder  Plier,  Fig.  92,  lute  the  ends 
of  the  plier  with  liquid  plumbago  to  prevent  them  from  adhering  to  the  work.  The 
joint  edges  of  the  band  should  come  evenly  and  perfectly  together.     In  soldering 


Fig.  92. 


all  parts  of  appliances,  the  pointed  blue  blaze  is  rarely  employed.  The  blaze  that 
is  made  with  less  air  blast  pressure  whose  greatest  heat  area  is  farther  away  from 
the  point  of  the  blowpipe,  and  of  a  more  distributing  character,  is  far  preferable 
and  safer.     Its  hottest  central  point  can  be  quite  as  accurately  directed;  and  it  is 


152 


FART    V.     PRIMARY   PRI \C[ I'l.ES  OF  PRACTICE 


safer,  because  its  softer  spreading  quality  distributes  a  more  general  heat  to  the 
surrounding  area  where  its  danger  degree  in  relation  to  the  fusing  point  of  the 
solder  ean  be  seen  and  guarded  against.  Remember  always,  that  the  solder 
should  be  forced  to  flow  throvigh  the  medium  of  the  heated  joint  or  surface 
to  be  soldered.  ( )ne  should  have  a  sufficient  number  of  these  inexpensive  solder 
pliers  to  enable  shaping  the  ends  to  properly  grasp  the  different  attachments  to 
be  soldered. 

In  soldering  bands,  direct  the  soft  blaze  of  the  blowpipe  always  upon  the 
ends  beneath  the  band  until  tlie  joint  starts  to  turn  red,  then  quickly  run  along  the 
joint  the  point  of  an  instrument  dipped  in  partially  liquified  borax  with  the  view 
of  drawing  the  subsequently  fused  borax  down  into  the  joint,  and  not  on  the  inside 
surface  of  the  band.  Then  place  a  very  small  piece  of  solder — only  sufficient  to 
fill  the  joint — exactly  over  the  joint  so  that  it  touches  both  sides,  and  continue 
the  heat  as  before,  always  beneath,  never  upon  the  band  itself,  or  upon  the  solder, 
until  it  is  fused  and  drawn  down  into  the  joint.  In  placing  the  small  piece  of 
solder,  it  may  first  be  touched  to  the  surface  of  the  liquified  borax.  If  the  heat 
can4es  it  to  one  side  of  the  joint,  stop  and  replace  it  exactly  over  the  joint; 
otherwise  it  is  likely  to  flow  on  to  the  inside  surface  of  the  band,  instead  of  being 
drawn  into  the  joint.  A  very  little  practice  will  enable  a  quick  performance  of 
this  part  of  the  operation  with  facility  and  perfect  accuracy. 

For  soldering  all  regulating 
appliances,  the  skillful  use  of  a 
perfect  blowpipe  is  far  prefer- 
able to  a  Bunsen  Burner,  or 
any  stationary  instrument.  In 
selecting  a  blowpipe,  it  should 
be  one  that  can  be  held  lightly 
in  the  hand,  so  as  to  be  manip- 
ulated easily  and  quickly  in 
response  to  demands.  The  Lee 
blowpipe,  shown  in  Fig.  93, 
which  is  operated  by  the  mouth, 
or  bellows,  is  one  that  answers 
the  purpose.  The  flame  is  eon- 
trolled  by  the  spring  lever  with 
which  the  gas  can  be  shut  off 
to  a  small  pilot  light.  For  those  who  have  air  pressure,  this  blowpipe  can  be 
easily  modified  to  form  one  of  the  most  convenient  instruments  for  all  purposes  of 
soldering.  This  is  accomplished  by  cutting  an  oblong  finger-hole  in  the  air  tube  of 
the  blowpipe,  through  which  is  passed  a  short  half-section  of  a  thin  tube  curved 
and  contoured  at  one  end,  as  shown  below  in  Fig.  94,  and  soft-soldered  to  the  inside 
of  the  air  tube,  as  shown  by  the  dotted  lines,  in  such  a  position  that  the  continuous 


Fig.  93. 


^ 


CHAPTER  XVIII.     COXSTRIL'TIOX    OF   BAXDS  153 

stream  of  air  under  pressure  is  directed  out  through  the  hole.    Around  the  hole  is 
soldered  an  elevated  rim  beveled  to  exactly  fit  the  end  of  the  forefinger.    This 

enables  one  to  completely  close  the  hole  with 

a  very  light  pressure.     When  the  finger  is  in 

.  -  =^^^^^^  -  place  covering  the  hole,  the  air  is  forced  over 

|l  ..         ...  ;  V,         v,^     the  curved  inner  lip  and  on  to  its  work  forming 

'''~'      "       '""         •  ~"  •   "^   the  air  blast. 

A  small  spur  is  soldered  to  the  side  of  the 
~r:>  pipe  to  which  is  attached  a  fine  spiral  spring 

which  connects  with  the  gas  lever.  The  flame 
is  controlled  with  the  thumb  (jn  the  spring  lever  which  when  released  shuts  the 
gas  down  to  the  pilot  light.  At  any  moment  the  operator  drops  or  hangs  up  the 
blowpipe,  the  spring  lever  is  released,  and  the  gas  shut  down  to  the  pilot  light, 
but  not  blown  otit  by  the  air  pressure  which  now  escapes  through  the  hole. 

The  main  advantage  in  this  device  is  that  it  enables  a  quick  and  delicate 
regulation  of  the  gas  and  air,  which  with  little  practice  becomes  an  involuntary 
movement.  With  small  work  that  is  not  invested,  only  sufficient  gas  and  air  should 
be  allowed  to  pass  the  valves  that  will  form  a  blaze  of  this  kind  about  two  inches 
long  to  its  extreme  end.  Before  commencing  to  solder,  only  a  trifle  more  than  the 
required  amount  of  air  should  be  turned  on  to  the  pipe,  and  this  is  further  regulated 
by  slightly  raising  the  finger.  Perfection  and  delicacy  of  adjusting  and  manipulat- 
ing the  blaze  is  of  the  greatest  importance  in  skillful  soldering. 

In  regard  to  the  solder,  it  is  quite  as  easy  and  safe  to  solder  nickel  silver  ap- 
pliances with  difterent  grades  of  gold  solder  as  with  silver  solder.  In  all  appliances 
where  gold  solder  is  to  be  used  throughout,  as  in  retaining  appliances,  the  joints 
of  the  bands  should  be  soldered  with  22k.  For  the  rest  of  the  work,  the  author  rarely 
employs  less  than  18k.  It  requires  far  more  care  to  use  a  low  grade  of  solder  than 
a  high  one — providing  of  course  that  the  fusing  point  of  the  solder  is  lower  than  the 
things  to  be  soldered — for  the  reason  that  a  slightly  overheated  thin  band  or  base 
will  quickly  absorb  and  become  alloyed  with  the  zinc  of  the  solder,  and  immediately 
fuse  or  "bum  out"  over  that  surface. 

Whenever  the  solder  of  any  kind  does  not  flow  freely,  or  "balls  up,"  so  to 
speak,  it  is  due  to  one  of  two  things:  First,  to  the  lack  of  borax,  and  second, — which 
is  commonly  the  cause  with  beginners — the  solder  itself  is  fused  before  the  joint  or 
surfaces  to  be  soldered  are  first  heated  to,  or  slightly  above,  the  fusing  point  of  the 
solder.  If  the  case  is  invested,  it  should  be  first  thoroughly  dried  out  over  a  Bim- 
sen  Burner,  and  when  it  is  placed  on  the  solder  block,  the  flaming  blaze  should  be 
directed  upon  the  investment  and  continued  until  the  bands,  at  the  point  to  be 
soldered,  commence  to  turn  slightly  red — as  in  free-hand  soldering — then  add  the 
borax  and  fuse  that,  and  then  the  solder.  Always  commence  the  blaze  back  on  the 
investment,  and  gradually  draw  the  heat  toward  the  band  or  joint  until  brought 
to  the  fusing  point  of  the  solder  which  will  then  flow  freely  into  the  joint ;  then  stop 


154  PART    V.     PRI.\[ARV   PRI \CI PI.F.S  OF   PRACTICE 

at  once,  and  add  more  solder  if  recjuired  to  complete  the  work.  If  the  heat  is  car- 
ried a  very  little  l)eyond  the  free  fusing  point  of  the  solder,  it  is  liable  to  alloy  the 
base  and  lower  its  fusibility,  and  this  is  one  of  the  main  causes  of  fusing  or  burning 

thin  bands. 

Silver  Solder 

The  most  perfect  flowing  silver  solder  is  made  in  large  quantities  of  chemically 
pure  silver,  copper,  and  zinc.  The  following  formula  is  fovmd  to  be  the  best  for  the 
three  grades  of  silver  solder  required  in  the  construction  of  regulating  appliances. 


No.  I 

Ko.  2 

Xo. 

Silver  Solder 

[c. 
'  c. 

p. 
p. 

Silver 
Copper 

8 

4 

8 
4 

8 
4 

,  c. 

p. 

Zinc 

I 

2 

3 

An  eight-ounce  crucible  is  first  completely  coated  on  the  inside  with  borax, 
using  a  gas  oxyhydrogen  funiace.  The  copper  of  one  of  the  grades  is  first  fvised, 
and  when  at  its  lowest  fusing  point,  the  silver,  in  small  pieces  or  pellets  is  added  one 
at  a  time,  increasing  in  amounts  vmtil  all  are  in.  Then  when  again  reduced  to  its 
lowest  fusing  point,  add  the  zinc — thrusting  small  pieces  into  the  mass  so  as  to 
bury  them  quickly  beneath  the  surface  to  prevent  oxidation  or  burning  them  up 
before  they  can  be  united  with  the  alloy.  The  alloy  is  then  brought  to  a  high  heat 
that  will  cause  it  to  roll  and  thoroughly  mix,  before  pouring  into  ingots  to  be  rolled 
to  28  gauge,  and  cut  into  1  pwt.  pieces. 


CHAPTER   XIX 

ADVANCED   PRINCIPLES   AND   TECHNICS   OF   REGULATING   BANDS 

Preliminary  Fitting  of  Bands. — After  the  joints  of  the  bands  have  been  soldered 
with  No.  1  silver  solder  or  22k  gold  solder,  the  projecting  ends  of  the  joints  should 
be  trimmed  off  close,  and  firmly  mashed  between  the  beaks  of  fitting  pliers,  and  then 
properly  contoured  to  fit  the  labial  and  lingual  surfaces  of  the  teeth.  It  is  usually 
an  advantage  to  fit  the  bands  to  the  natural  teeth  to  correct  any  imperfection 
in  size,  and  to  mark  the  position  and  direction  of  attachments.  In  giving  to  the 
band  the  exact  shape  of  its  tooth  form,  it  insures  greater  perfection  to  the  fit  of 
attachments,  especially  those  of  the  long  tubes  upon  molars. 

At  this  time  the  proximal  borders  of  the  bands  may  be  trimmed  so  they  will 
not  extend  beneath  the  borders  of  the  gums  or  lie  upon  occlusal  surfaces.  When- 
ever it  is  necessary  that  the  edges  must  extend  under  the  gingivae,  they  should 
always  be  carefully  burnished  to  fit  the  surfaces  of  the  teeth  at  the  time  of  cement- 
ing them.  Where  attachments  are  to  be  soldered  to  front  bands  merely  for  the 
Fig.  9.5.  purposc  of  bow  rcsts,  or  where  there  is  no 

great  tendency  of  the  force  to  dislodge  the 
band,  the  labial  surfaces  may  be  consider- 
ably narrowed.  An  apparatus  requiring 
a  very  small  alignment  arch-bow  for  the 
retrusion  or  alignment  of  the  labial  teeth  can  in  this  way  be  made  quite  incon- 
spicuous. In  most  drawings  of  apparatus  in  this  work,  the  bands  are  shown  wide  for 
the  purpose  of  more  distinctly  illustrating  the  attachments  and  their  respective  posi- 
tions.   They  should  not,  therefore,  be  viewed  as  the  finished  band  in  this  particular. 

Fig.  90. 


The  lingual  and  buccal  portions  of  molar  and  premolar  bands  should  be  con- 
toured and  the  sharp  edges  filed  preparatory  to  the  final  finishing,  as  shown  in 
sample  bands,  Fig.  95. 

155 


156  PART    V.     PRIMARY   PRIXCIPI.ES  OF   PRACTICE 

The  instruments  necessary  for  the  above  work  are :  Curved  Scissors,  Fig.  96, 
a  six-inch  half-round  jeweler's  file  No.  6,  a  six-inch  rat-tail  iile  No.  o,  and  the  Band 
Contouring  Pliers,  Fig.  97.    The  latter  arc  far  more  perfectly  adapted  for  this  work 

Fig.  97. 


than  the  ordinary  crown  contourers,  as  they  are  constructed  to  avoid  crimping  the 
edges  of  the  band. 

The  Technics  of  Band  Fitting. — One  of  the  essentials  to  the  perfect  retention  of 
a  band,  is  that  it  should  fit  the  teeth  as  tightly  as  it  can  be  driven  on.  Some  writers 
have  instructed  that  the  bands  should  fit  somewhat  loosely,  so  as  to  leave  space 
for  the  cement;  this  is  about  as  reasonable  as  leaving  a  space  for  the  cement  or 
glue  in  mending  broken  earthen  or  glassware,  or  in  making  a  wood  joint. 

In  taking  the  measurements  it  requires  considerable  practice  to  draw  a  band 
■ — especially  the  thicker  ones — around  a  tooth  tightly,  and  sharply  bend  it  for  the 
joint;  nor  can  it  be  done  as  easily  with  any  of  the  ordinary  pliers  as  with  those  of 
more  delicate  ends  having  somewhat  sharp  edges,  which  will  bite  into  the  band 
material  itself  while  pressing  the  band  against  the  tooth  in  bringing  the  joint  sur- 
faces closely  together. 

Again,  in  burnishing  the  joint  preparatory  to  soldering:  if  the  joint  has  not 
been  sharply  marked,  it  requires  considerable  judgment  to  avoid  leaving  the  band 
too  large,  by  failing  to  force  the  joint  sufficiently  into  the  grasp  of  the  burnishing 
pliers.  In  fitting  a  band  on  a  tooth  after  it  is  soldered,  if  it  is  found  to  be  slightly 
too  small  it  can  be  easily  enlarged  on  the  horn  of  an  anvil. 

Relation  of  Coronal  Zones. — It  is  not  stated  in  Black's  admirable  and  exhaustive 
"Dental  Anatomy,"  or  elsewhere  to  the  author's  knowledge,  that  the  circumference 
measurements  of  the  diflferent  coronal  zones  of  teeth  bear  quite  a  definite  anatomic 
relation  to  each  other.  This  is  believed  by  the  author  to  be  an  important  factor 
in  the  consideration  of  fitting  bands  to  the  crowns.  It  teaches  that  bands  which 
are  properly  proportioned  in  this  regard  can  be  forced  on  the  crowns  of  any  of  the 
teeth  and  fit  their  surfaces  with  considerable  accuracy,  from  an  occlusal  line  even 
with  the  contact  points,  to  a  gingival  line  near  the  proximo-gingival  borders  of 
enamel.  The  relative  circumference  of  these  zones,  which  are  marked  by  the 
edges  of  the  band,  and  the  zone  that  lies  midway  between,  will  be  found  quite 
definite  in  all  teeth  of  the  same  character. 

The  relative  circumferences  of  the  crowns  of  incisors  and  cuspids — upper  and 
lower — gradually  taper  in  size  from  the  gingival  to  the  occlusal  zones.   The  incisors 


CHAPTER  XIX.    TECHNICS  OF   REGULATING  BANDS  157 

taper  in  the  proportion  of  2  to  1  in  -i  inches,  and  the  cuspids  2  to  1  in  1  inch.  That 
is  to  say,  bands  of  the  proper  size  that  are  made  to  fit  mandrels  which  taper  in  this 
proportion  will  qviite  accurately  fit  these  teeth  from  the  mesio-distal  angles  to  the 
linguo-gingival  ridges. 

With  upper  premolars  and  the  upper  and  lower  first  and  second  molars,  the 
gingival  band  zones  are  about  the  same  size  as  the  occlusal,  but  the  largest  zone  lies 
between,  somewhat  nearer  to  the  gingival.  If  these  bands  are  made  of  the  proper 
size  upon  a  mandrel  which  tapers  in  the  proportion  of  2  to  1  in  12  inches,  and  of  a 
width  that  covers  well  the  buccal  and  lingual  surfaces,  and  are  festooned  so  as  not 
to  cover  the  occluso-mesial  and  occluso-distal  ridges  on  the  one  hand,  or  extend 
far  beneath  the  interproximate  gingivae  on  the  other,  and  then  are  contotired  on 
the  buccal  and  lingual  sides  so  as  to  draw  in  the  occlusal  edges,  the  bands  will  be 
found,  when  driven  on,  to  fit  these  teeth  quite  accurately  from  the  gingival  to  the 
occlusal  margins. 

With  lower  premolars  the  occlusal  and  gingival  zones  are  about  the  same  size, 
the  two  zones  lying  nearer  together  and  with  no  marked  difference  between  them 
in  proportional  taper.  If  bands  are  made  for  these  teeth  of  the  proper  size,  with 
very  slight  taper,  and  as  above,  in  other  particulars,  they  will  be  found  to  fit  with 
sufficient  accuracy  for  all  practical  purposes. 

From  this  it  will  be  seen  that  if  bands  are  shaped  and  contoured  properly 
and  are  of  the  right  size  and  taper  they  may  be  driven  on  the  crowns  to  a  point 
where  they  will  tightly  fit  all  the  surfaces.  Again,  there  is  usually  so  much  dif- 
ference between  the  general  sizes  of  the  right  and  left  tooth,  even  though  not  per- 
ceptible to  the  eye,  that  if  the  bands  are  transposed  they  will  commonly  be  sur- 
prisingly too  large  or  too  small.  Therefore,  in  taking  the  measurements,  a  model  or 
form  should  always  be  at  hand  upon  which  the  bands  can  be  placed  in  their  re- 
spective places  when  removed  from  the  teeth ;  a  precaution  that  shovild  be  strictly 
observed  throughout  the  entire  construction  of  the  apparatus. 

Placing  Bands. — In  placing  a  band  upon  a  tooth,  one  should  be  able,  on  account 
of  the  slight  conical  shape  of  the  tooth  and  band,  to  force  it  nearly  to  place  with  the 
fingers  or  thumb,  if  the  spaces  between  the  teeth  will  ]jermit;  after  this  the  use 

Pig.  98. 


0 

of  a  hickory  or  hardwood  Band  Plugger,  Fig.  98,  used  with  a  heavy  mallet,  is  in- 
valuable. The  broad  and  somewhat  yielding  surface  of  the  wood  resting  upon  the 
edge  of  a  band — especially  when  it  is  nearly  in  place — will  not  double  or  mar  the 
edge  as  will  any  steel  instrument.  It  will  also  catch  the  edge  that  has  passed  the 
occlusal  angle  and  enable  one  to  force  it  to  a  more  perfect  fitting  than  seems 
possible  with  an}i;hing  else. 


158 


FART   V.     PRIMARY  PRINCIPLES  OP  PRACTICE 


A  heavy  Lead  Mallet,  one  weighing  6  ounces,  will  be  found  far  more  effective 
and  cause  less  pain  to  the  patient  than  one  of  the  ordinary  lighter  kinds  used  for 
filling.  With  the  same  amount  of  momentum,  the  velocity  is  decreased  in  propor- 
tion to  the  weight,  producing  a  blow  that  approaches  a  push  force,  without  re- 
bound, and  being  one  of  a  more  distributing  quality,  will  not  produce  the  amount 
of  shock  to  sensitive  teeth  which  often  obtains  in  the  use  of  lighter  mallets. 

Removal  of  Bands. — The  removal  of  bands  that  have  been  driven  on  the  teeth 
for  trial,  or  to  mark  position  of  attachments,  is  made  easy  with  the  Band  Removing 

Fig.  09. 


Pliers,  Fig.  99.  These  are  constructed  with  one  jaw  to  engage  with  the  gingival 
edge  of  the  band,  while  the  other,  which  is  longer  and  turned  at  right  angles,  is  shod 
with  copper  to  rest  upon  the  occlusal  surface  and  act  as  a  fulcrum,  without  danger 
of  cracking  the  enamel.  The  shape  of  the  extreme  end  of  the  fulcrum  beak  is  such 
that  while  retaining  its  position  upon  the  tooth,  it  enters  the  band  as  it  is  being 
lifted,  thus  permitting  its  free  disengagement.  These  pliers  are  indispensable  for 
the  removal  of  cemented  and  uncemented  bands,  for  the  purpose  of  changing  their 
position  or  to  add  attachments  for  the  application  of  other  forces.  The  reciprocal 
action  of  the  two  beaks  causes  little  or  no  strain  upon  the  teeth  and  consequently 
a  minimum  amount  of  pain  to  patients,  as  would  certainly  always  arise  in  such  an 
attempt  with  a  free  hand  action  of  any  instrument  lifting  or  pulling  upon  the  band. 
Slitting  the  Bands. — When  a  preservation  of  the  band  is  unnecessary  and 
its  removal  is  at  all  difficult,  it  should  be  cut  with  the  slitting  pliers,  Fig.  100. 

Fig.  100. 


The  longer  fulcrum  beak  is  shod  with  copper  to  rest  upon  the  occlusal  surface 
of  the  tooth  without  injury  to  the  enamel,  while  the  shape  of  the  cutting  beak  is 
peculiarly  adapted  for  slitting  the  band. 


CHAPTER  XIX.     TECIIMCS  OF  REGULATING  BANDS  159 

Soldering  Attachments. — Preparatory  to  soldering  attachments,  the  bands 
should  be  hrst  festooned  and  the  premolars  and  molars  perfectly  contoured,  and 
then  replaced  upon  the  plaster  model  or  natural  teeth  in  the  exact  position  they  are 
intended  to  occupy,  in  order  to  determine  and  mark  the  correct  positions  and  direc- 
tions of  the  attachments.  In  removing  the  bands,  the  natural  tooth  shape  of  the 
bands  should  be  preserved,  especially  for  fitting  and  soldering  long-bearing  attach- 
ments. For  long  rotating  and  molar  tubes,  groove  the  band  with  a  fine  round  or 
joint  file  to  give  the  tube  a  long  bearing  close  seating,  while  preserving  the  natural 
contovir  of  the  band.  The  ends  of  the  anchorage  tubes  should  not  project  more 
than  is  necessary  to  freely  turn  the  nuts;  and  where  no  distal  nuts  are  to  be  used, 
bevel  and  finish  the  ends  of  the  tubes  to  prevent  the  laceration  of  tissues. 

In  some  instances  when  a  part  of  the  apparatus  is  complicated,  or  requires 
special  care  as  to  the  position  of  the  attachments  in  relation  to  the  teeth  and  gums, 
and  in  the  construction  of  stationary  anchorages  and  retaining  appliances,  a  plaster 
impression  of  the  teeth  with  the  bands  in  position  with  a  view  of  placing  them  on 
an  investment  model  in  the  exact  positions  they  occupied  on  the  teeth,  will  be 
found  necessary. 

The  only  objection  to  this  procedure  in  all  cases,  is  the  necessity  of  heating 
up  a  large  model  when  the  soldering  of  the  attachments  can  usually  be  accom- 
plished far  more  easily  and  safely  while  held  in  the  solder  pliers,  and  with  sufficient 
perfection,  if  their  positions  have  been  properly  marked  upon  the  bands. 

Management  of  Solder  and  Blowpipe. — When  the  attachment  is  in  place  on 
the  band,  and  held  in  the  grasp  of  the  solder  plier,  lightly  throw  a  spreading — 
not  a  pointed — blaze  from  the  blowpipe  over  the  point  to  be  soldered,  heating  it  to 
a  near  red;  then  quickly  toixch  the  point  with  lic[uified  borax  to  cover  only  that 
portion  where  the  solder  is  to  flow.  Follow  this  immediately  with  a  soft  blaze  as 
before  vintil  the  borax  is  thoroughly  fused  between  the  joints,  then,  and  not  until 
then,  place  over  the  joint  or  into  it  a  piece  of  No.  2  solder  nearly  if  not  fully  suffi- 
cient for  the  whole  of  that  immediate  work,  and  direct  the  same  character  of  blaze, 
not  upon  the  solder,  but  with  the  view  of  heating  up  the  surfaces  or  joint  to  be 
soldered,  and  niake  this  heated  area  fuse  the  solder  and  draw  it  into  the  joint.  If 
the  solder  becomes  oxidized  over  its  surface  in  a  half -fused  condition,  cjuickly 
touch  it  with  more  borax,  and  continue  the  heat,  which  will  at  once  cause  it  to 
flow  to  place.  When  you  see  the  solder  suddenly  jump  to  its  place,  stop  at  once. 
Too  much  heat  at  this  point  will  cause  the  zinc  of  the  solder  to  alloy  the  nickel 
silver  band,  lowering  its  quality  and  weakening  it.  For  the  same  reason  never  use 
the  No.  3  solder,  except  in  places  where  there  is  danger  of  loosening  a  previously 
soldered  attachment.  In  fact,  in  all  soldering  whether  of  silver  or  gold,  the  higher 
grades  of  solder  when  used  with  skill,  will  be  found  to  flow  far  more  evenly,  safely, 
and  perfectly  than  the  lower  grades. 

Construction  of  Bands  for  the  Midget  Appliances. — ^In  the  construction  of  all 
front  bands  and  their  attachments,  an  endeavor  should  be  made  to  make  them  as 


160  PART   V.     PRIMARY   PRIXCIPI.FS  OF   PRACTICE 

inconspicuous  as  possible.  The  front  bands  of  the  Midget  Appliances,  and  also 
those  for  the  bodily  labial  movement  of  children's  teeth,  afford  an  opportunity 
to  exercise  this  desire  to  a  greater  degree  than  any  of  the  other  appliances  as 
follows : 

When  the  front  bands  are  soldered  with  22k  gold  solder,  and  their  joints  mashed, 
they  are  placed  on  the  teeth  and  driven  firmly  to  place.  As  some  of  the  bands 
will  go  further  on  the  teeth  than  others  producing  an  unevenness  in  their  line,  this 
should  be  noted  and  an  even  gingival  line  marked  on  the  front  with  a  steel  point. 
The  bands  are  then  removed,  and  their  gingival  edges  are  evened,  and  their  occlusal 
edges  are  festooned  with  the  curved  scissors  to  the  minimum  of  width  along  this 
line,  which  need  not  be  wider  in  the  middle  than  one-eighth  of  an  inch,  and  even 
less  if  attachments  are  to  span  the  joints.  The  bands  are  then  slightly  contoured 
on  the  front  to  fit  the  curves  of  the  teeth,  and  again  placed  on  the  teeth  to  verify 
their  alignment;  finally  shape  the  front  surfaces.  Moreover,  a  careful  removal  of 
the  bands  after  the  final  fitting  is  important  so  that  they  will  retain  the  form  of  the 
teeth,  because  over  the  entire  front  of  each  of  these  bands  is  flowed  a  thin  layer 
of  18k  gold  solder  which  stiffens  and  strengthens  them. 

Nothing  adds  so  much  to  the  artistic  eflect  of  appliances  as  an  evenness  in 
the  width  and  relation  of  the  bands  to  the  occlusal  edges  of  the  front  teeth.  The 
object  in  flowing  the  18k  solder  over  the  front  of  the  band  is  twofold:  First,  no 
other  solder  is  required  in  placing  the  attachments ;  all  that  is  necessary  is  to  hold 
the  attachments  in  place  with  the  solder  plier,  and  direct  the  pointed  blue  blaze 
of  the  blowpipe  upon  the  (ithiclniicnt  until  the  solder  beneath  starts  to  fuse.  Second, 
because  of  its  quality  and  light  color,  it  gives  to  the  bands  a  durable  and  pleasing 
finish. 

In  this  process,  the  band  is  held  freely  in  the  solder  plier,  and  the  laliial  surface 
gently  brought  to  a  red  heat  with  a  soft  blaze  flared  back  and  forth;  then  add 
borax  and  flush  it  over  the  entire  front  surface  with  the  same  kind  of  gentle  heat. 
Then  add  the  gold  solder  commencing  at  the  joint,  and  fuse  it  in  the  same  manner, 
causing  the  heat  to  carry  it  completely  and  evenly  over  the  surface.  This  should 
entirely  obliterate  the  appearance  of  the  joint. 

The  labial  attachments,  of  various  forms  to  meet  all  requirements,  are  shown 
enlarged  in  Fig.  101.  A  shows  a  long  open  tube  attachment  with  very  thin  wall  to 
be  employed  for  retention  of  position.  When  closed  around  the  arch-bow,  which 
these  attachments  should  exactly  fit,  they  present  a  smooth  finish.  B  and  C 
show  variations  in  correcting  malturned  teeth  through  the  resilient  forces  of  very 
light  arch-bows,  the  wire  ligature  being  employed  until  the  bow  can  be  inclosed 
in  both  short  open  tube  attachments.  D,  E  and  F  show  different  views  of  the 
finger-spur  attachment,  which  is  the  method  most  frequently  employed  with  light 
resilient  bows,  Nos.  24  to  26,  for  the  rotation  and  alignment  of  incisor  teeth.  Tiny 
abridged  U-tubes  are  soldered  on  these  bands  in  positions  to  meet  the  requirements 
of  intrusive  or  extrusive  movements  and  to  steady  the  bow.     The  finger-spurs 


CHAPTER  XIX.     TECHNICS  OF  REGULATIXG  BANDS 


161 


are  cut  from  No.  24  annealed  wire  and  flattened  at  one  end  on  the  anvil.  These 
are  soldered  to  the  extreme  distal  or  mesial  surfaces  permitted  by  the  crowded 
position.  When  the  arch-bow  is  in  position  in  the  tubes,  it  is  sprung  lingually, 
and  the  finger-spurs  are  bent  sharply  over  it  with  a  pair  of  pliers  so  as  to  exert 
a  rotating  force ;  the  surplus  ends  are  then  cut  off.  This  maj^  need  to  be  repeated 
in  subsequent  treatments — each  time  making  a  new  bend  in  the  finger-spurs 
until  the  position  of  the  teeth  is  corrected. 


The  finger-spurs  are  also  of  great  value  in  the  correction  of  marked  malalign- 
ments when  little  or  no  rotation  of  the  tooth  is  required.  The  spur  is  bent  sharply 
in  the  form  of  an  L  at  the  flattened  end,  and  soldered  at  any  point  upon  the  front 
of  the  band  to  exert  the  proper  pulling  force.  The  finger-spur  is  then  lapped 
over  the  bow  as  before.  G  and  H  show  the  common  hook  attachment.  When 
employed  with  the  very  light  resilient  bows,  Nos.  24,  25,  and  26,  they  are  made  by 
rolling  No.  23  (.0225")  round  wire  to  a  thickness  of  about  .018".  This  is  bent 
sharply  with  thin  flat-nosed  pliers  to  the  desired  form  and  finished  neatly  so  that  it 
will  project  no  more  than  slightly  beyond  the  bow  when  in  place. 


162 


PART    V.     PRIMARY    PRIXCIPLES  OF   PRACTICE 


Fig.  102  shows  the  double  hook  or  bracket  which  is  useful  at  times  for    the 
attachment  of  intermaxillary  elastics  in  the  correction  of  open-bite  malocclusions. 

Fii..  1(12. 


^ 


The  hooks  and  brackets  can  be  more  easily  made  with  the  crimping  plier 
shown  in  Fig.  103;  these  can  then  be  cut  into  the  proper  sizes  for  the  required 
attachments.  With  these  tiny  attachments  some  difficulty  may  be  experienced 
in  placing  and  holding  them  in  position  imtil  they  can  be  grasped  by  the  solder 


R 

b 


Fig.  103. 


pliers.  This  is  easily  obviated  by  slightly  moistening  the  surface  of  the  band, 
which  will  cause  the  attachment  to  cling  while  it  is  being  teased  to  the  right  position 
to  be  grasped.  A  very  gentle  heat  from  a  slightly  spreading  pointed  blaze  from  the 
blowpipe  will  fuse  the  gold  solder  which  has  been  previously  spread  over  the  front 
of  the  band  as  described,  and  this  will  solder  the  attachment. 

Finishing  and  Plating 

After  the  necessary  attachments  are  soldered  to  the  bands,  they  are  boiled 
about  fifteen  minutes  in  a  solution  of  sulphuric  acid,  and  neutralized  in  a  solution 
of  sal  soda,  then  thoroughly  rinsed  in  hot  water;  this  is  to  remove  the  borax  and 
loosen  the  oxide  preparatory  to  polishing  and  plating  them.  In  finishing  the  bands, 
hold  them  on  a  wood  mandrel  somewhat  the  form  and  taper  of  the  respective 
teeth.     All  sharp  and  projecting  portions  that  are  likely  to  irritate  the  mucous 


CHAPTER  XIX.    TECHNICS  OF  REGULATING  BANDS 


163 


membrane  should  be  removed  with  a  file,  or  with  a  fine  emery  wheel,  and  the  sur- 
faces rounded,  smoothed,  and  polished  with  tripoli  on  a  felt  wheel  and  a  coarse 
hair  brush  wheel ;  then  a  fine  brass  wire  brush  wheel  is  used  for  the  final  polishing 
and  burnishing.  If  care  has  been  observed  to  prevent  oil  or  grease  of  any  kind 
from  coming  in  contact  with  the  parts,  from  the  hands,  or  otherwise,  while  polish- 
ing, they  can  be  carried  immediately  into  the  plating  solution. 

When  the  appliances  are  of  platinum  and  gold  alloy,  if  highly  polished  and 
kept  in  that  condition,  they  present  a  far  more  artistic  and  inconspicuous  ap- 
pearance without  gold-plating. 

Fi(^.  101. 


The  Plating  Outfit  for  regulating  appliances  employed  by  the  author  is  shown 
in  Fig.  104.  It  takes  its  cvuTent  directly  from  the  Edison  110-volt  direct  current 
through  the  medium  of  a  series  current  tap  supporting  a  16-candle-power  lamp. 
If  this  seems  to  produce  a  current  of  too  high  voltage,  it  may  be  reduced  one-half 
by  inserting  an  8-candle-power  lamp.  Where  the  direct  cuiTcnt  is  not  at  hand, 
a  single  one-gallon  cell  (Daniel,  Smee,  Bunsen,  or  preferably,  an  Edison  Lelande) 
can  be  substituted. 

The  gold-plating  solution  advised  by  the  author  is  made  by  dissolving  30 
grains  of  Mallinckrodt's  Gold  Chloride  in  about  one  quart  of  hot  distilled  water; 
then  add  chemically  pure  cyanide  of  potassium  vmtil  the  solution  is  clear;  it  can 
be  used  cold  or  slightly  warmed.  This  solution  contains  far  less  cyanide  than  the 
usual  solution  recommended,  and  will  be  found  to  preserve  the  anode  much  longer. 
Use  for  an  anode  a  piece  of  pure  gold  plate  about  two  inches  square;  this  should 
be  removed  from  the  solution  when  not  in  use.  After  plating  the  parts,  polish 
with  whiting  on  a  soft  hair  brush  wheel. 

The  Personal  Factor  in  Technics 

When  one  is  properly  equipped  with  all  the  requisite  tools,  implements,  and 
material,  the  construction,  or  personal  direction  and  supervision  of  the  construc- 
tion of  regulating  appliances  in  the  ofiice  laboratory  will  be  found  one  of  the  great- 
est pleasures  in  the  practice  of  orthodontia,  and  one,  moreover,  that  will  require 


164  PART   V.     PRIMARY  PRfXCIPLES  OF  PRACTICE 

less  time  and  annoyance  with  far  more  assurance  of  perfect  applicability  than 
the  selection  and  fitting  of  commercial  appliances.  Besides,  nearly  all  com- 
mercial appliances  demand  considerable  fitting  and  soldering;  then  why  not  go 
a  little  further  and  solder  the  attachments  to  the  bands,  and  thus  be  sure  that 
they  are  exacth-  in  the  right  places  and  attitudes  for  performing  the  most  effec- 
tive work? 

This  does  not  mean  that  one  shall  prepare  banding  material,  tubing,  or  threaded 
bows,  bars,  nuts,  jackscrews,  etc.,  or  prepare  the  stock  material  for  the  small  at- 
tachments, all  of  which  may  be  purchased,  but  it  is  an  appeal  to  orthodontists 
to  construct  or  have  constructed  in  their  own  laboratories,  under  their  immediate 
supervision  and  personal  aid,  the  regulating  appliances  used  in  their  practice,  and 
made  exactly  accoi'ding  to  a  plan  which  they  have  previously  thought  out  as  the 
most  efficient  for  the  case,  or  better  still,  from  a  drawing  of  the  whole  appara- 
tus set  up  on  the  teeth,  showing  sizes,  positions,  etc.,  etc.  A  very  little  practice 
along  these  lines  will  show  how  easily  this  can  be  accomplished,  while  the  efficiency 
and  satisfaction  to  be  derived  goes  without  saying.  It  is  remarkable,  moreover, 
how  qviickly  girls  learn  to  do  this  work,  neatly  and  with  dispatch,  because  they 
enjoy  it;  besides,  they  are  more  dependable  than  boys  and  men. 

Advantages  of  Nickel  Silver. — There  are  many  reasons  in  favor  of  the  em- 
ployment of  nickel  silver  in  preference  to  gold  or  platinized  gold,  etc.,  in  the  general 
construction  of  regulating  apparatus.  The  nickel  silver  material  is  fully  as  harm- 
less for  the  teeth  and  gums  as  any  of  the  royal  metals.  (Jne  of  the  things  in  favor 
of  nickel  silver  bands  is:  the  material  is  softer  and  can  be  more  easily  and  per- 
fectly fitted  to  the  depressions  on  the  lingual  surfaces  of  the  incisors  and  along 
gingival  borders  than  the  platinized  metals,  and  therefore,  less  likely  to  loosen  from 
the  teeth  or  to  leave  spaces  for  the  washing  out  of  the  cement. 

The  fusing  point  of  nickel  silver  is  sufficiently  adequate  for  every  practical 
purpose.  For  instance,  in  constructing  the  retainers,  the  joints  of  the  incisor 
bands  which  are  not  over  .003"  or  No.  40  B.  &  S.  gauge,  are  soldered  easily  with 
22k  gold  solder,  and  for  the  rest  of  the  work  not  less  than  18k  solder  may  be  safely 
used  by  one  who  is  skillful  in  its  management,  thus  entirely  covering  the  nickel 
silver  bands  with  the  gold  solder  and  reinforcements. 

The  main  argument  in  favor  of  nickel  silver  is  not  because  of  the  difference 
in  cost,  which  of  course  amounts  to  considerable  in  a  large  practice,  but  it  is  the 
perfect  willingness  and  even  desire  on  the  part  of  the  operator  to  at  once  remove 
and  throw  away  any  apparatus  or  part  as  soon  as  it  is  found  to  have  done  its  work, 
or  is  not  quite  perfect,  and  replace  it  with  another.  He  is  not  trying  to  make  it 
do,  when  he  knows  it  ought  to  be  changed,  nor  is  he  saving  the  bows  and  bands  for 
another  case  for  which  they  are  not  perfectly  adapted.  As  for  the  difference  in 
appearance — for  that  is  all  that  it  really  amounts  to — the  gold-plated  nickel  silver 
is  certainly  objectionable  when  compared  to  the  fresh  clear  white-metal  appliances, 
but  when  the  nickel  silver  is  highly  polished,  and  not  plated,  there  is  comparatively 


CHAPTER  XIX.     TECHNICS  OF  REGULATING   BANDS  165 

no  difference  in  appearance ;  and  while  the  latter  is  perhaps  more  likely  to  become 
tarnished  in  the  mouth,  unless  there  is  a  perfect  co-operation  on  the  part  of  the 
patient  or  parents  in  keeping  regulating  appliances  of  whatever  metal  clean  and 
polished — which  is  always  possible — they  all  soon  become  tarnished  and  turn 
dark  at  points  which  are  difficult  to  reach  with  the  brush. 

Boys  are  usually  far  more  difficult  to  control  in  this  regard  than  girls,  because 
they  have  less  pride.  But  parents  should  be  made  to  vmderstand  at  the  outset, 
that  it  is  incumbent  upon  them  to  attend  to  this  necessity,  and  if  they  fail,  they 
shotdd  be  called  sharply  to  account,  for  the  difference  in  appearance  of  the  appli- 
ances is  small  compared  to  the  danger  to  the  teeth  if  great  care  and  attention  is 
not  given  to  cleanliness  during  the  regulating  process. 


CHAPTER  XX 

MODERN   PRINCIPLES   AND   METHODS   IN   ORTHODONTIA 

111  order  to  bring  to  the  minds  of  students  some  of  the  most  modern  methods 
in  orthodontia,  it  has  been  deemed  advisable  to  devote  this  chapter  to  the  history 
and  treatment,  from  start  to  finish,  of  a  somewhat  complicated  case  in  the  author's 
practice,  revised  from  a  paper  which  was  read  before  the  American  Society  of 
Orthodontists  in  1917. 

Three  Characters  of  Malocclusion  in  One  Case. — The  object  in  selecting  this 
particular  case  for  this  purpose,  is  that  it  presents  a  combination  of  several  dis- 
tinctive malpositions,  and  a  variety  of  distinctive  characters  of  movements,  with 
the  requirement  of  a  number  of  different  kinds  of  appliances  for  its  correction  and 
retention.  It  will  give  an  opportunity  to  describe  from  a  practical  standpoint 
the  efficiency  and  value  of  the  new  midget  appliances  for  correcting  the  alignment 
of  the  teeth  for  children  and  youths;  the  value  of  direct  intermaxillary  elastics 
in  the  correction  of  open-bite  malocclusions;  the  value  and  modern  technics  of 
comparatively  light  appliances  for  the  bodily  labial  movement  of  the  upper  front 
teeth;  the  principle  and  practical  application  of  torsional  force  for  the  bodily 
expansion  of  arches;  the  value  and  practical  action  of  the  working-retainer;  and 
finally,  the  finished  result  with  the  regular  retaining  appliances  in  place. 

The  case  is  one  of  peculiar  interest  and  applicability,  because  in  the  first  place 
it  teaches  the  importance  of  a  careful  and  thorough  study  of  every  case,  however 
apparently  simple  and  uncomplicated  it  may  at  first  appear,  and  why  an  artistic 
observation  of  the  facial  outlines  should  be  regarded  as  one  of  the  foundation 
principles  of  intelligent  diagnosis: 

It  shows  how  there  may  arise  three  distinctive  characters  of  malocckision 
from  the  local  cause  of  adenoids  followed  with  long  continued  early  mouth- 
breathing  and  inhibited  maxillary  development,  i.  e.,  decided  malalignments 
of  the  permanent  teeth,  open-bite  or  infra-occlusion  of  the  front  teeth,  and  finally, 
a  bodily  retruded  position  of  the  upper  incisors  and  entire  intermaxillary  process. 

It  will  conclusively  demonstrate  the  remarkable  effectiveness  of  the  resilient 
forces  of  exceedingly  light  arch-bows  and  delicately  constructed  bands  and  unique 
attachments.  It  will  show  the  most  modem  technique  and  application  of  the 
regular  bodily  movement  apparatus  whose  principles  of  force  have  been  success- 
fully employed  for  twenty-five  years  for  the  connection  of  the  most  extensive 
retrusions  and  protrusions.  This  was  originally  named  the  "contouring  appara- 
tus." It  was  afterwards  discovered  that  this  same  principle  of  applying  force  to 
the  teeth,  according  to  the  law  of  levers  of  the  third  kind,  was  quite  as  applicable 

166 


CHAPTER  XX.     MODERX  PRINCIPLES  AXD  METHODS 


167 


for  bodily  lingual  or  retruding  movements  of  the  front  teeth;  and  in  recent  years 
this  same  mechanical  principle  has  been  extensively  employed  for  bodily  move- 
ments of  the  teeth  in  every  direction.  In  fact,  no  teeth  were  ever  moved  bodily, 
except  through  the  application  of  this  principle  of  force,  which  consists  in  the 
establishment  of  independent  points  of  fulcrtim  and  power  in  relation  to  the 
alveolus  or  area  of  work.  Even  that  addition  to  our  technic  principles  of  tor- 
sional force  for  the  bodily  movement  of  teeth  presented  recently  by  Dr.  Angle 
and  exemplified  in  his  new  "pin  and  tube"  and  "  bracket  and  ribbon"  appliances, 
is  reducible  in  its  direct  action  to  that  of  a  lever  of  the  third  kind. 

Fig.  10.5. 


The  first  impressions  of  this  case — the  plaster  casts  of  which  are  shown  in 
Fig.  105,  were  taken  September  27,  1916,  and  are  those  of  a  miss  thirteen  years  of 
age.  Both  right  and  left  sides  of  the  denture  were  so  alike  in  buccal  occlusion,  it  is 
unnecessary  to  show  but  one  side.  As  will  be  observed  by  an  examination  of  the 
buccal  occlusion,  the  upper  denture  is  slightly  distal  to  normal,  and  the  tipper 
incisor  teeth,  though  appearing  to  be  prominent  at  their  occlusal  edges,  distinctly 


168  PART   V.     rRI\r  [RV    PRIXCIPI.ES  OF   PRACTICE 

show  l)y  the  rclruded  facial  oullincs  that  tlicy  arc  quite  labially  inclined  from  deep- 
ened incisive  fossae.  The  apparent  prominence  of  the  upper  incisor  crowns  is 
enhanced  by  the  retruded  position  of  the  lower  incisors,  which  was  caused  by  the 
criminal  extraction  of  a  lower  lateral  incisor  which  happened  to  erupt — as  incisors 
often  do — in  lingual  malalignment.  From  the  facial  cast,  it  can  be  seen  that  the 
chin  and  lower  lip  are  quite  perfectly  posed,  and  in  harmonious  relation  to  the 
main  or  unchangeable  features  of  the  physiognomy,  showing  that  the  mandible 
and  lower  denture  are  in  normal  dento-facial  relations.  The  moderately  retruded 
outlines  of  the  upper  part  of  the  upper  lip  with  the  abnormal  deepened  naso- 
labial lines,  enhancing  the  prominence  of  the  cheek  bones,  gave  to  the  physiog- 
nomy— especially  from  a  front  view — an  unnatural  and  decidedly  unesthetic 
broad  and  flattened  appearance.  The  facial  diagnosis,  in  connection  with  the 
retruded  relations  of  the  upper  incisors  and  raarked  open-bite  malocclusion, 
definitely  indicates  that  its  cause  was  early  adenoids  and  mouth-breathing;  the 
former  inhibiting  the  normal  development  of  the  maxilla,  and  the  latter — -which 
doubtless  continued  through  several  years  of  early  development — resulted  in 
the  open-bite  malocclusion. 

From  the  above  diagnosis  it  will  at  once  be  observed  that  the  case  belongs 
in  Class  III  of  the  dento-occlusal  classification,  and  that  the  main  and  imperative 
part  of  the  operation  demands  a  bodily  labial  movement  of  the  upper  incisors 
and  incisive  alveolar  process,  accompanied  by  a  general  maxillary  expansion  and 
alignment  of  the  teeth  through  bone-growth  development,  to  correct  dental  and 

facial  relations. 
"'  ^™'  The    Midget    Apparatus. — In    all    cases    in 

which  a  bodily  movement  of  the  front  teeth  is 
demanded,  it  is  first  quite  imperative  that  the 
front  teeth  be  placed  in  alignment  so  that  they 
can  be  brought  evenly  within  the  firm  grasp 
of  the  power  arch-bow,  and  thus  moved  bodily 
in  phalanx.  For  the  purpose  of  accomplishing 
this  first  stage  of  the  operation,  and  incidentally 
to  correct  the  alignment  of  the  lower  teeth  and 
open-bite  malocclusion,  the  first  apparatus  worn 
is  that  shown  in  Fig.  106  which  is  similar  in 
general  character  to  that  which  has  been  com- 
monly employed  by  the  author  for  years  in  the 
correction  of  all  simple  irregularities  and  malpositions  of  the  teeth  of  children  and 
youths.  It  is  that  which  derives  its  main  motive  force  from  the  resiliency  of  very 
light  arch-bows  which  range  in  diameter  sizes  from  Nos.  22  to  26  (.025"  to  .016'  ). 
To  those  who  are  not  familiar  with  the  gauge  sizes,  it  may  be  well  to  state  that  No. 
22  is  about  the  size  of  a  small  pin,  and  No.  26  is  but  a  trifle  larger  in  diameter  than 
the  thickness  of  a  28-gauge  plate  with  which  all  dentists  are  familiar. 


CHAPTER  XX.    MODERN  PRINCIPLES  AND  METHODS  169 

There  is  no  objection  to  employing  any  of  the  alloys  of  gold  and  platinum  for 
the  arch-bows,  if  specially  drawn,  but  for  all  intents  and  purposes  18  per  cent 
nickel  silver  spring  wire  if  properly  drawn,  will  answer  every  requirement.  Ortho- 
dontists who  have  not  tested  the  possibilities  of  high-grade  nickel  silver  can  hardly 
realize  the  higher  degree  of  spring  temper  and  resiliency  that  can  be  given  to  arch- 
bows  of  this  material  when  drawn  cold  from  very  much  larger  sizes. 

Pig.  107. 


The  arch-bows  of  the  above  small  sizes,  if  intended  for  the  purposes  referred 
to,  should  be  drawn  from  Nos.  14  to  16  high-grade  spring  nickel  silver  wire,  without 
annealing,  and  kept  cold  in  the  process  with  a  small  bag  of  crushed  ice  placed  over 
the  draw  plate. 

The  particular  characters  of  malocclusion  for  which  these  very  light  resilient 
arch-bows  are  especially  adapted,  are  those  which  are  commonly  composed  of  a 
variety  of  m.alpositions  which  arise  during  the  early  eruptive  stages  of  the  per- 
manent teeth,  and  which  are  commonly  due  to  local  causes.     In  the  apparatus 


170 


PART    V.     PRIMARY   PRIXCIFLES  OF  PRACTICE 


Fin.  lOS. 


shown  in  Fig.  l(ir»,  the  arch-bows  are  No.  26.  Tn  the  l)racket  attachments  on 
the  lower  incisors,  the  gingival  hooks  are  for  direct  intermaxillary  elastics  to  aid  in 
closing  the  open-bite.  See  "Construction  of  Bands  for  the  Midget  Appliances," 
Chapter  XVIIl.  After  this  apparatus  was  placed  on  the  teeth  and  the  patient 
instructed  in  the  adjustment  of  the  elastics,  the  case  was  not  seen  oftener  than  once 
in  two  weeks.  Occasionally  at  these  times,  the  arch-bows  were  removed  and  re- 
placed with  new  ones,  and  minor  treatments  performed  as  the  changing  conditions 
demanded. 

Bodily  Movement  Apparatus. — In  less  than  four  months  after  the  case  was 
started,  the  upper  front  teeth  being  sufficiently  in  alignment  for  the  bodily  move- 
ment apparatus,  the  appliances  were  removed  and  impressions  were  taken  for  the 
models  shown  on  the  right  of  Fig.  107.  On  the  left  is  a  view  of  the  beginning  models. 
It  was  at  this  time  that  the  bodily  movement  apparatus,  shown  in  Fig.  108,  was 
made  and  placed.  The  power  arch-bow  in  this  case  is  No.  16  spring  nickel  silver 
rolled  to  a  ribbon  form  of  about  y^  of  its  diameter  over  the  labial  area,  and 
placed  to  apply  its  force  at  the  gingival  line  of  the  front  teeth. 

For  the  younger  class  of  patients,  the 
power  is  now  rarely  applied  above  the  gingival 
margins,  and  often  the  fulcrum  bow  is  placed 
near  the  middle  of  the  crowns.  It  must 
be  seen  however,  that  the  farther  the  line  of 
power  is  placed  from  the  area  of  alveolar 
work,  and  the  nearer  it  is  to  the  artificial 
fulcrum,  it  proportionately  decreases  its  me- 
chanical advantage  for  bodily  movement, 
and  consequently  increases  the  strain  upon 
the  power  arch-bow  and  its  molar  anchorages. 
The  object  in  applying  the  power  upon 
root-wise  attachments  to  the  front  teeth, 
is  to  increase  the  mechanical  advantages  of  the  whole  apparatus,  which  is  quite 
important  when  extensive  bodily  movements  of  front  teeth  arc  demanded  for 
older  patients. 

If  one  wishes  to  combine  with  this  the  torsional  bodily  force,  he  can  easily 
construct  the  hooks  to  exactly  fit  a  ribboned  portion  of  the  power  arch-bow,  as 
shown  by  Fig.  62,  Chapter  XIV.  The  bow  is  rolled  at  such  an  angle  that  when 
placed  in  its  front  attachments,  the  distal  ends  of  the  bow,  at  equilibrium,  will 
stand  below  the  occlusal  plane,  from  which  they  are  sprung  upward  into  their  posi- 
tions in  the  U  or  open  tubes.  It  would  be  advisable,  however,  from  some  experience 
which  the  author  has  had  with  this  method,  that  the  fvilcrum  bow  be  not  omitted, 
and  the  power  bow  be  not  less  than  No.  19. 

The  Technics  of  Attachments. — The  incisor  attachments  for  bodily  labial 
movements  for  young  patients  are  made  in  the  following  manner:   No.  18  (.040") 


CHAPTER  XX.     MODERN  PRINCIPLES  AND  METHODS 


171 


a. 


of  the   band. 


nickel-silver  or  platinum-gold  wire  is  rolled  to  about  ^  its  diameter, 
as  shown  in  the  enlarged  view  of  Fig.  109  ("a").  At  one  end,  on 
the  fiat  side  of  the  rod,  a  groove  is  filed  ("b"),  using  a  jeweler's  fine 
cut  joint-file.  This  file  is-g- of  an  inch  thick,  ^  inch  wide,  and  cut 
only  on  its  edges  half-round.  The  end  is  then  rounded  off  so  as  to 
form  a  ciuarter-round  open  tube  at  the  end  of  the  bar  having  a  wall 
thickness  of  .005"  ("c"),  designed  to  grasp  the  small-sized  fulcrum 
arch-bow  when  closed  around  it.  The  line  of  the  fulcrum  arch-bow 
should  be  fully  32  of  an  inch  above  the  incisal  ends  of  the  laterals. 
The  distance  from  the  fulcrum  grooves  to  the  gingival  border  of  the 

lateral  bands,  having  been  determined  by 
exact  measurement  of  the  tooth,  the  bar  is 
then  grasped  in  heavy  pliers,  or  a  small  vise, 
and  sharply  bent  at  right  angles  at  this  point 
("d"),  using  a  small  hammer  to  perfect  the 
sharpness  of  the  right  angle.  It  is  then  bent 
back  in  the  form  of  a  hook  or  staple  ("e"), 
being  careful  not  to  disturb  the  right-angled 
bend  which  represents  the  gingival  border 
the  root-wise  attachment   ("f")    is  formed 


Fig.  ^w. 


I 


Fig.  110. 


The  finished  hook  of 

to  fit  the  labial  faces  of  the  incisors,  and  to  support  the  power 
and  fulcnim  arch-bows,  as  shown  in  Fig.  110.  Its  position  in 
relation  to  the  band  should  be  such  as  to  allow  the  power  bow 
to  span  the  interproximal  gingivae.  It  should  not  extend  above 
the  power  arch-bow,  which,  being  always  at  tension,  requires 
but  a  slight  groove  to  prevent  it  from  slipping  off;  otherwise,  it 
would  be  difficult  if  not  impossible  to  lift  the  bow  from  its 
attachments  at  any  time  when  desired.  The  fulcrum  bow  is  a 
No.  23  (.0225  ')  alignment  bow  threaded  at  one  end.  After 
placing  it  the  ends  of  the  upright  attachments  are  closed  around 
the  wire  to  make  a  smooth  finish. 
It  will  be  seen  that  the  right-angled  gingival  bend  of  this  attachment,  starting 
as  it  does  from  the  gingival  margin  of  the  band,  and  ending  in  a  fitted  hook  for 
the  power  bow,  presents  a  mechanical  principle  of  great  strength,  and  enables 
the  application  of  more  than  sufficient  power  through  the  medium  of  a-  very  deli- 
cate mechanism.  In  the  construction  of  appliances  for  bodily  labial  movements 
which  demand  the  application  of  a  greater  bodily  mechanical  advantage  above  the 
gingival  margins  for  the  older  class  of  patients,  the  root-wise  extensions  of  the  at- 
tachments require  to  be  made  much  heavier  where  they  join  the  bands,  because 
the  line  of  force  is  far  to  one  side  of  their  line  of  attachment  to  the  teeth,  and  from 
that  point  they  may  be  tapered  to  a  finished  edge,  thus  securing  reqviired  strength 
with  the  least  amount  of  material. 


172  PART  V.     PRIMARY   PRINCIPLES  OF  PRACTICE 

In  soldering  the  attachment  to  the  band,  place  it  to  one  side  of  the  joint  on 
the  band,  and  grasp  it  with  the  solder  plier,  which  for  this  purpose  is  grooved  on 
one  of  its  grasping  points  for  a  firm  seating  on  the  attachment. 

The  power  arch-bow  for  this  apparatus  may  be  No.  18,  or  17  (.040",  .045"), 
spring  nickel  silver,  or  platinized  gold.  A  roimd  wire  bow  is  much  more  rigid  than 
one  that  is  flattened,  and  less  conspicuous.  If  flattened  at  all,  it  should  be  only 
over  the  incisors.  It  is  important  that  it  be  shaped  to  lie  evenly  over  the  gingival 
surfaces  in  front,  but  distal  to  the  cuspids  it  should  take  a  straight  line  to  its 
anchorage  tubes  to  insure  its  rigidity.  It  goes  without  saying  that  a  power  arch- 
bow  for  bodily  labial  movement  of  the  incisors,  which  necessarily  bends  nearly 
at  a  right  angle  from  its  front  attachments  to  its  molar  anchorage,  must  possess 
considerable  rigidity  to  prevent  the  push  force  from  springing  it  buecally.  The 
power  anchorage  tubes  should  lie  evenly  with  the  line  of  the  bow  so  that  the 
threaded  ends  will  rest  evenly  in  the  open  tubes. 

In  assembling  this  apparatus  for  its  final  fitting  and  adjustments,  place  the 
anchorages  first  and  then  the  power  arch-bow,  adjusting  its  relations  in  front  with 
the  anchorage  lock  nuts.  Finally,  in  placing  the  incisor  bands,  see  that  the  gingival 
hooks  for  the  power  bow  are  properly  adjusted  so  that  they  will  not  press  the 
bow  into  the  gums,  and  also  that  the  bow  can  be  lifted  from  its  seating  without 
injury  to  the  gums,  which  might  arise  if  the  hooks  lapped  on  to  the  bow  too  far. 
It  is  at  this  point  in  the  preliminary  fitting  that  the  final  bend  of  the  hooks  should 
be  made.  This  is  accomplished  by  grasping  the  band  in  the  root-wise  plier,  one  beak 

Fig.  111.  Fig.  112. 


of  which  fits  over  the  attachment  (Figs.  Ill  and  112).  The  hook  is  then  safely 
given  its  final  bend  to  adjust  the  relations  of  the  power  bow  to  the  gums.  These 
rules  apply  also  to  the  fitting  and  adjustment  of  the  more  root-wise  power  attach- 
ments. The  same  order  of  assembling  the  apparatus  is  pursued  in  the  final  placing 
and  cementing.  The  fulcrum  arch-bow  is  placed  last.  So  far  as  strength  is  con- 
cerned, a  midget  arch-bow  No.  26  (.016"),  or  even  an  Angle  wire  ligature  would 
be  sufficient,  but  these  small  wires,  vmder  the  strain  of  considerable  traction  force, 
are  likely  to  press  on  the  cuspids  and  narrow  the  labial  arch. 

Fig.  113  was  made  from  a  photograph  of  one  of  the  lighter  forms  of  contour- 
ing apparatus  where  the  power  arch-bow  may  be  no  larger  than  No.  18,  or  19 
(.040"  or  .035")   spring  nickel   silver  or  platinum  gold,  and  the  fulcrum  bow, 


CHAPTER  XX.    MODERN  PRINCIPLES  AND  METHODS  173 

No.  26  (.016    ).     The  U-power  anchorage  tube  is  not  shown  in  this  illustration 
because  it  occurs  only  upon  the  right  side. 

If  the  case  is  a  pronoimccd  retrusion  of  the  entire 
upper  denture  with  full  mesial  nialinterdigitation  of 
the  lower  buccal  teeth,  the  author  has  learned  from 
many  vinsatisfactory  experiences  that  it  is  not  advis- 
able to  shift  the  dentures  to  a  normal  occlusion,  except 
for  very  young  patients,  because  of  the  improbability 
of  permanency  of  retention.  Instead,  spaces  are 
opened  between  the  premolars  of  the  retruded  den- 
tures for  the  insertion  of  artificial  premolars.  This 
rule  in  the  author's  practice  applies  also  to  pronounced  inherited  retrusions  of  the 
lower  dentures  in  those  cases  where  the  chin  is  in  normal  pose  and  the  upper  denture 
is  not  materially  protruded.  It  is  mentioned  here,  because,  if  the  case  is  one  of  this 
character,  the  reaction  of  the  fulcrum  force  may  be  utilized  in  the  mesial  movement 
of:  first,  the  cuspids,  as  shown,  and  then,  the  first  premolars  to  open  spaces  for  the 
insertion  of  retaining  artificial  teeth.  The  insertion  of  artificial  teeth  absolutely 
prevents  a  retrusive  movement  of  the  crowns  of  the  front  teeth,  but  they  must 
not  be  expected  to  take  the  place  of  the  regular  retainer  whose  main  function  is  to 
prevent  the  roots  from  returning  toward  their  former  positions  until  nature  has 
been  given  time  to  equilibrate  and  solidify  the  surrounding  alveolar  structure. 
See  Chapter  XLII. 

There  are  no  cases  in  orthodontia  which  so  forcibly  and  invariably  tend  to 
return  to  their  former  positions  after  treatment  as  inherited  retrusions  of  the  den- 
tures which  have  demanded  for  their  con-ection  a  bodily  labial  movement,  or 
none,  moreover,  in  which  there  is  greater  need  for  the  fulfillment  of  the  highest 
principles  of  retention. 

The  amount  of  correction  of  the  open-bite  at  this  stage  of  the  case  under 
consideration  is  shown  on  the  right  of  Fig.  107,  as  compared  to  that  on  the  left. 
This  was  accomplished  mainly  by  direct  intermaxillary  elastics  attached  to  the 
midget  hook  and  bracket  attachments  upon  the  front  teeth. 

At  the  anniversary  clinic  of  the  Chicago  Dental  Society,  January  27,  1917, 
four  months  after  the  case  was  started,  the  patient  attended  by  her  older  sister, 
kindly  consented  to  appear  and  submitted  to  hours  of  examination  and  question- 
ing by  hundreds  of  dentists.  She  was  wearing  at  that  time  the  upper  contouring 
apparatus  shown  in  Fig.  113.  The  plaster  dental  and  facial  casts,  and  the  mounted 
apparatus  which  had  accomplished  its  work  up  to  that  time,  were  shown  and  ex- 
plained. The  author  is  particular  to  mention  this  circumstance — parenthetic- 
ally— because  it  establishes  the  imquestionability  of  the  above  dates. 

From  the  presentation  of  the  true  chronological  history  of  this  case,  some 
might  imagine  that  rapidity  of  orthodontic  movements  should  be  regarded  as  a 
test  of  the  value  of  the  appliances,  whereas,  it  will  be  found  throughout  the  entire 


174  PART    V.     PRIMARY   PRINCIPLES  OP  PRACTICE 

teaching  in  this  work  that  that  particular  phase  of  an  operation  is  ncghgiblc  com- 
pared to  the  selection  and  application  of  methods  which  are  best  suited  to  the  needs 
of  the  case  in  hand,  and  the  methods  which  will  accomplish  the  most  favorable 
results.  In  fact,  the  best  accomplishments  cannot  be  attained  in  the  correction 
of  many  cases  of  malocclusion  in  an  attempt  to  hurry  the  operation.  While 
time,  ease  of  adjustments,  painlessness,  non-irritability,  and  artistic  effect  are  of 
great  importance,  they  should  never  stand  in  the  way  of  the  true  principles  of 
practice.  Occasionally,  as  in  this  instance,  we  will  meet  with  cases  which  safely 
respond  with  phenomenal  rapidity,  if  the  forces  are  skillfully  adjusted  to  their 
needs. 

The  second  lower  apparatus,  which  is  shown  in  Fig.  108  was  placed  a  few 
weeks  after  the  patient  had  become  accustomed  to  the  upper.  The  lower  front  teeth 
were  nearly  in  alignment,  and  consequently  in  a  position  to  be  more  firmly  grasped 
by  a  No.  23  expansion  arch-bow  which  would  sustain,  with  greater  stability,  the 
distances  between  the  molars  and  front  teeth,  and  exert  a  slight  general  expanding 
force,  and  at  the  same  time  permit  the  proper  action  of  the  disto-mesial  elastics 
for  the  reinforcement  of  the  upper  anchorages,  and  the  adjustment  of  the  occlusion. 
Provision  will  be  seen  on  the  lower  for  the  direct  intermaxillary  elastics  to  continue 
the  extruding  force — particularly  the  upper  cuspids  and  first  premolars. 

It  should  not  be  inferred  that  the  forces  of  any  of  these  appliances  alone  were 
the  only  treatments  employed,  because  in  this,  as  in  nearly  every  case,  the  skillful 
orthodontist  will  employ  subsidiary  forces  as  the  case  progresses,  which  are  quite 
as  important  as  the  main  forces  for  keeping  the  machinery  in  perfect  co-ordinating 
action.  With  the  author,  these  side  forces  are  mainly  obtained  with  light  silk 
ligatures  and  elastics.  Moreover,  it  is  the  office  rule  that  when  bands  or  their 
attachments  have  outgrown  their  usefulness,  or  are  not  properly  constructed 
or  adjusted  to  perform  their  best  work,  they  are  immediately  removed  and  correct- 
ed— more  often  with  new  bands  and  attachments  for  varying  the  forces. 

There  is  one  thing  to  which  attention  is  particularly  called  as  a  recent  and 
most  important  improvement  in  the  technics  of  anchorages.  It  is  the  employment 
of  the  U  or  open-tubes,  instead  of  closed  or  seamless  round  tubes,  for  the  anchorage 
ends  of  the  arch-bows  as  shown  in  Fig.  108.  For  the  very  light  resilient  bows,  a 
seamless  tube  on  one  side,  and  a  U  or  open-tube  on  the  other  are  usually  sufficient. 
But  for  the  larger  bows,  with  locked  attachments  to  the  front  teeth,  which  are 
designed  to  exert  a  bodily  expanding  force,  U  or  open-tube  anchorage  tubes  are 
invaluable,  because  they  enable  giving  to  the  bow  any  desired  spring  force,  and 
with  assured  ease  of  assembling.  And  then  when  desired,  the  ends  can  be  readily 
lifted  from  the  tubes  and  given  an  extra  spring  force  and  replaced  without  the 
necessity  of  unlocking  the  bow  from  its  front  attachments.  This  is  especially  im- 
portant for  the  more  rigid  power  arch-bows  of  the  bodily  movement  apparatus. 
It  occasionally  becomes  necessary  to  remove  these  bows  to  increase  or  decrease 
their  expanding  properties,   or  to  correct  some  irritating  action  that  arises  at 


CHAPTER   XX.     MODERN  FRIXCIPLES  AXD  METHODS  175 

the  front.  Formerly,  this  was  impossible  without  a  complete  removal  of  all  the 
front  bands,  or  the  stationary  anchorages;  and  this  is  not  always  an  easy  operation, 
without  slitting  them.     Now,  the  counter-sunk  nuts,  shown  in  Fig.  114,  which  lock 

Fu..  114. 


r 


the  ends  of  the  bow  in  the  tubes,  are  unscrewed  and  the  bow  is  easily  lifted  out  of 
its  attachment  at  the  back,  and  then  at  the  front,  and  as  easily  replaced,  without 
disturbing  any  of  the  bands.  The  drawing  shows  the  way  to  cut  the  ends  of  open 
tubes  to  fit  the  counter-sunk  depression  in  the  nuts;  but  if  U-tubes  are  used, 
the  comers  of  the  open  lips  should  be  cut  back  so  that  the  counter-sunk  nut  will 
draw  the  bar  or  bow  deeply  into  the  tubes.  See  latest  locking  device  for  power 
U-anchorage  tubes,  Fig.  210,  Chapter  XLII. 

The  importance  of  applying  the  anchorage  power  above  the  gingival  margins 
upon  root-wise  anchorage  attachments  shown  in  Fig.  108  cannot  be  overestimated. 
This  places  the  direction  of  the  power  more  nearly  in  a  line  with  the  center  of 
alveolar  resistance,  and  proportionately  increases  the  stability  by  decreasing  the 
tendency  to  inclination  movement.  The  root-wise  method  of  applying  force  is 
invaluable  in  all  bodily  movements.  Besides  the  labio-lingual  bodily  movement 
of  the  front  teeth,  it  is  of  great  advantage  in  the  bodily  expansion  of  dental  arches, 
and  in  the  bodily  disto-mesial  movements  of  both  the  front  and  back  teeth  to  close 
interproximate  spaces  from  whatever  cause,  where  it  is  important  to  avoid  incli- 
nation movement. 

Bodily  Working-Retainer.  To  return  to  the  case  under  consideration:  After 
the  bodily  movement  apparatus  had  been  worn  about  four  months,  the  patient  was 
obliged  to  return  to  her  home  in  Oklahoma  on  account  of  the  sickness  of  her 
father,  which  would  prevent  the  author  from  seeing  her  until  near  the  close  of  the 
operation.  As  the  bodily  movement  of  the  upper  teeth  and  the  general  correction 
of  the  malocclusion  had  progressed  quite  favorably,  and  fearing  to  trust  to  others 
in  this  advanced  stage  the  treatment  adjustments,  the  author  decided  to  place  the 
bodily  working-retainer  on  the  upper  incisors  which  would  continue  more  slowly 
but  safely  their  bodily  movement. 

Fig.  115  shows  two  views  of  the  working-retainer  on  the  model  of  the  upper 
teeth  at  this  time.  The  lingual  push  bars  are  No.  19  spring  nickel  silver,  fitted 
but  not  soldered  into  the  thick  wall  clasp-metal  tubes  which  are  attached  to  the 
clasp-metal  reinforcement-backing  of  the  retainer.  The  distal  ends  of  the  bars  at 
equilibrium  are  about  ^^s  of  an  inch  below  the  occlusal  plane,  and  when  sprung 


176 


PART    V.     PRnrARV   PRINCIPLES  OF   PRACTICE 


into  the  U  or  oix'n-tiilx'  attachments  on  the  hnj^ual  surfaces  of  the  stationary 
anchorages,  they  exert  a  labial  force  upon  the  roots  of  the  incisors;  this,  in  con- 
nection with  the  acti(;n  of  the  nuts  at  the  mesial  ends  of  the  anchorage  tvibes, 


Fig.  II.- 


results  in  a  bodily  labial  movement.  The  open  sides  of  the  tuljes  cannot  be  seen 
in  the  illustration  because  they  are  turned  toward  the  roof  of  the  mouth;  this  causes 
the  spring  bars  to  be  locked  in  place  without  closing  the  tubes. 


Fi(,.  IK'. 


The  object  of  the  two-band  stationary  anchorages  is  to  distribute  the  extrusive 
spring  force  of  the  bars  and  -prevent  a  supra-occlusal  movement,  as  would  natu- 
rally occur  if  this  force  were  sustained  by  single  molar  anchorages.  The  disto- 
mesial  and  direct  intermaxillary  and  other  forces  were  continued  with  this  appara- 


CHAPTER   XX.     MODERX   PRIXCIPLES   AXD   METHODS 


111 


tus.      The  working-retainer  is  fully   described  under   "Principles  and   Technics 
of  Retention,"  in  Chapter  LIV. 

During  the  absence  of  the  patient,  she  very  faithfully  kept  up  the  application 
of  the  various  forces.  On  Wednesday,  August  29,  1917,  eleven  months  after  the 
case  was  started,  all  the  appliances  were  removed,  and  the  impressions  were  taken 
for  the  plaster  casts  shown  in  Fig.  116.  Notwithstanding  the  unfortunate  fact  that 
there  are  only  three  lower  incisors,  the  dentures  are  in  fair  occlusion,  which  time 
will  improve.  Below,  is  a  front  occlusal  view  of  the  teeth  with  the  final  retainers 
in  position.  You  may  be  able  to  see  the  supplemental  spurs  for  the  attachment  of 
the  direct  intermaxillary  retaining  elastics  for  continuing  the  extrusive  force,  to 
prevent  a  return  of  the  infra-occlusal  position,  and  also  the  hooks  on  the  lower 
for  continuing  the  disto-mesial  intermaxillary  force. 


'1.;.  in 


Fig.  117  will  give  a  fair  idea  of  the  development  in  the  facial  outlines  by  im- 
mediate comparison  with  the  beginning  facial  cast  on  the  left.  The  plaster  im- 
pression for  the  one  in  the  middle  was  taken  upon  the  removal  of  the  regular 
bodily  movement  apparatus  which  was  worn  about  four  months.  The  impression 
for  the  one  on  the  right  was  taken  upon  the  removal  of  the  entire  regulating  appa- 
ratus. The  protruded  prominence  of  the  roots  of  the  incisors  are  very  faintly 
shown  in  the  illustration.  If  the  upper  incisors  are  retained  in  their  present  bodily 
labial  position,  the  facial  outlines  will  no  doubt  continue  to  improve  through  stim- 
ulated growth  development. 


PART  \T 


Practical  Treatment 

of 

Dento- Facial  Malocclusions 


CLASSES   OF    DENTO-FACIAL   MALOCCLUSIONS 


Class  I.    Normal  Disto-Mesial  Occldsion  of  the  Buccal  Teeth 
Class  II.    Distal  Malocclusion  of  Lower  Buccal  Teeth 
Class  III.  Mesial  Malocclusion  of  Lower  Buccal  Teeth 

For  General  Classified  Table  of  Divisions  and  Classes,  see  page  19 
For  Table  of  Types  and  Divisions  of  Class  I,  see  page  199 
For  Table  of  Types  and  Divisions  of  Class  II,  see  page  245 
For  Table  of  Divisions  of  Class  III,  see  page  290 


DENTO- FACIAL  MALOCCLUSIONS 


CHAPTER   XXI 

ORTHODONTIC  PRINCIPLES  OF  DIAGNOSIS  AND  GENERAL  RULES  OF 
TREATMENT  OF  ALL   CLASSIFIED   MALOCCLUSIONS 

^'°"  ^^'"^^  Introduction. — This    chapter   relates   particularly 

to  the  foundation  principles  and  diagnosis  of  dento- 
facial  malocclusions,  with  general  outlines  of  treat- 
ment. It  also  comprises  a  comparison  of  the  dififerent 
characters  which  have  deceptive  similarities,  with  the 
view  of  establishing  their  treatment  upon  an  artistic 
and  scientific  basis. 

In  order  to  accomplish  this  most  successfully,  one 
should  have  in  mind  a  standard  of  perfection  of  facial 
outlines.  In  other  words,  one  should  be  able  to  see 
in  the  mind's  eye  the  symmetrical  outlines  to  be 
worked  for  or  toward  in  the  correction  of  the  case 
in  hand. 

Fig.  118  represents  the  common  relations  which  the 
lips  sustain  to  the  teeth  in  normal  dento-facial  posi- 
tion and  occlusion.  The  facial  outlines  of  this  figure 
will  be  employed  throughout  Classified  Malocclusions 
as  a  standard  of  comparison  solely  for  the  purpose  of 
showing  the  probable  degree  of  disharmonies  in  the 
facial  outlines  in  different  characters  and  types  of 
protrusion  and  retrusion  of  the  teeth  and  jaws. 
While  it  is  important  to  observe  the  occlusion,  the  malalignments  and  mal- 
relations  of  the  teeth  and  jaws  to  each  other,  the  diagnosis  should  always  be 
accomplished  with  an  intelligent  and  artistic  observation  of  dento-facial  outlines. 
There  is  no  other  way  of  determining  the  real  character  of  a  case  or  the  direction 
and  degree  of  movement  demcDided  in  its  correction.  In  a  diagnosis  and  prognosis 
of  malocclusion,  a  disregard  of  facial  outlines  and  the  marring  eflfects  which  mal- 
relations  of  the  teeth  and  jaws  produce,  or  a  belief  that  "the  attainment  of  a 
normal  occlusion  will  always  result  in  the  most  perfect  correction  of  dento-facial 
imperfections  and  deformities,"  is  rapidly  taking  its  rightful  place  as  one  of  the 
fantastic  theories  of  the  past. 

181 


182  PART    17.     I)  EN  TO-FACIAL   MALOCCLUSIONS 

Those  who  appreciate  and  desire  the  highest  attainment  in  practice  must  in 
time  bccnme  convinced  that  the  only  true  basis  of  diagnosis  and  treatment  is 
dento-facial  harmony — harmony  in  the  occlusal  relations  of  the  dentures  to  each 
other  for  purposes  of  mastication,  and  harmony  in  the  dento-facial  area  and  its 
relations  to  the  other  features.  It  includes  a  normal  occlusion  of  the  teeth  as  one 
of  its  highest  attainments,  except  in  those  comparatively  rare  instances  where 
extraction  is  demanded  to  correct  or  prevent  a  dento-facial  deformity,  and  it 
always  includes  an  adequate  masticating  occlusion  with  the  most  exact  inter- 
digitation  of  buccal  cusps  it  is  possible  to  attain. 

In  a  consideration  of  the  facial  outlines  of  the  three  classes  of  malocclusion, 
there  will  be  found  in  each  class  a  variety  of  distinctive  types  which  differ  quite 
as  much  from  each  other  as  they  dift'er  from  many  of  the  types  of  other  classes. 
In  fact  the  facial  effects  in  a  number  of  instances  in  different  classes  will  be  found 
quite  similar,  being  due  to  similar  dento-facial  malpositions  of  the  front  teeth; 
and  yet  because  of  the  difference  in  buccal  occlusion,  they  demand  for  their  cor- 
rection quite  different  treatment.  Therefore,  true  diagnosis  for  determining  the 
character  and  treatment  of  all  marked  cases  of  malocclusion  can  only  be  success- 
fully accomplished  by  a  careful  and  intelligent  stud}'  of  the  facial  outlines  in 
connection  with  the  dental  irregularity,  particularly  the  buccal  occlusion,  and 
finally,  the  probable  caixses,  mainly  with  the  view  of  determining  whether  from 
local  or  inherent  origin. 

It  is  always  possible,  and  it  is  usually  not  difficult  to  produce  a  normal  occlu- 
sion of  the  dentures  by  a  judicious  application  of  intermaxillary  force.  But  the 
question  should  arise:  "Will  such  an  extensive  movement  of  the  teeth  as  this 
often  portends,  leave  the  overlying  features  imdeformed,  or  not  as  perfect  as  might 
be  produced  with  a  lesser  movement  which  would  secure  to  the  patient  fully  as 
perfect  masticating  forces  and  with  a  greater  probability  of  permanency  of  reten- 
tion?" While  a  normal  occlusion  should  be  regarded  as  imperative  in  the  correc- 
tion of  a  very  large  majority  of  all  malocclusions,  the  contemplation  of  its  attain- 
ment should  always  be  based  upon  an  intelligent  understanding  of  the  effect 
which  this  condition  of  the  dentures  will  produce  upon  the  facial  outlines.  More- 
over, in  the  disto-mesial  shifting  of  the  buccal  teeth  to  a  normal  occlusion,  it  is  of 
the  greatest  importance  at  times  to  govern  the  extent  of  the  movement  of  one 
denture  or  the  other  to  obtain  the  best  facial  effect.  This  principle  is  especially 
outlined  in  the  treatment  of  Class  II. 

Standards  of  Diagnosis. — In  the  diagnosis  and  treatment  of  all  dental  mal- 
occlusions which  produce  disharmonies  in  the  facial  outlines,  a  mental  standard 
of  comparison  is  imperative.  In  almost  every  act  of  our  lives  there  is  or  should 
be  a  guiding  mental  standard  of  perfection.  In  the  art  of  speaking  perfectly,  there 
should  be  a  fixed  mental  standard  of  true  articulation  and  phonation  in  the  enun- 
ciation of  all  the  oral  elements  of  speech.  This  in  phonology  is  named  the  "correct 
sound-image."     In   the  practice  of  orthodontia,  and  especially  in  diagnosis,  we 


CHAPTER   XXI.     DIAGNOSIS  AND   TREATMENT  183 

should  have  firmly  fixed  in  our  minds  a  perfect  understanding  and  appreciation 
of  normal  occlusion  and  dento-facial  harmony.  The  ability  to  establish  a  mental 
standard  of  beauty  should  not  be  confined  to  a  fixed  idea  of  the  facial  outlines  of 
classic  art  as  shown  in  that  of  the  Apollo  Belvedere,  but  it  should  be  one  which  may 
be  adjusted  in  the  mind's  eye  to  the  different  types  of  physiognomies  which  present 
for  treatment,  according  to  the  rules  laid  down  in  the  following  principles  of  Diagno- 
sis. Thus  the  most  desirable  harmony  in  the  dento-facial  area  it  is  possible  to  pro- 
duce in  the  correction  of  every  dental  irregularity,  may  be  determined  and  attained. 

In  a  normal  occlusion  of  the  teeth,  the  condyles  of  the  mandible  rest  in  their 
most  posterior  positions  in  the  glenoid  fossae;  while  the  incisal  edges  of  the  lower 
labial  teeth  pass  slightly  back  of  those  of  the  upper. 

The  labial  teeth  and  all  of  that  portion  of  the  adjoining  osseous  structure 
which  it  is  possible  to  move  with  dental  appliances,  constitute  the  main  framework 
of  the  dento-facial  area.  And  while  no  artistic  or  mathematical  rules  can  be  laid 
down  as  a  standard  of  facial  beauty  because  of  the  variety  of  dift'erent  types  that 
are  denominated  as  "beautiful,"  it  is  nevertheless  true  that  certain  standards  of 
physical  relation  must  always  obtain  with  every  physiognomy  which  lies  within 
the  field  of  what  is  termed  beauty  and  esthetic  perfection. 

As  the  chin  should  always  be  sufficiently  prominent  in  relation  to  the  lower 
lip  to  produce  no  suggestion  of  a  "receding  chin,"  the  antero-posterior  relations  of 
the  lower  teeth  to  the  mandible — upon  which  this  portion  of  the  facial  outlines 
depend — should  be  such  as  to  bring  into  decided  evidence  the  graceful  concave 

Fig.  119. 


curve  of  the  labio-mental  depression.  The  normal  closure  of  the  lower  labial 
teeth,  slightly  back  of  the  upper  labial  teeth,  permits  the  desired  esthetic  harmony 
in  the  relations  of  the  upper  and  lower  lips.  If,  therefore,  the  upper  labial  teeth 
in  arch  alignment  are  not  protruded  or  retruded  in  relation  to  the  bones  which 
form  the  framework  of  the  middle  features  of  the  physiognomy,  the  upper  lip 
will  also  assume  the  desired  form  and  pose  in  relation  to  the  cheeks,  malar  prom- 


184  PART    VI.     DEMO-FACIAL  MALOCCLUSIONS 

inences,  and  bridge  of  the  nose,  and  this  is  nt-eessary  for  the  perfeetion  of  this 
l^ortion  of  the  facial  outhnes. 

To  complete  the  esthetic  requirements  of  this  enscnihle  of  dento-facial  liarmony, 
the  perfect  ease  and  pose  of  the  lips  when  closed  and  at  rest  are  largely  dependent 
\i])on  the  harmony  in  distance  between  the  upper  and  lower  jaws  when  closed  with 
the  muscles  relaxed  in  relation  to  the  labial  and  buccal  tissues.  If  an  infra-occlusal 
or  intrusive  malposition  of  the  buccal  teeth  causes  the  jaws  to  come  too  closely 
together,  as  in  short  and  close-bite  malocclusion,  the  redundancy  of  labial  and 
buccal  tissue  is  evidenced  by  the  pouting  attitude  of  the  lips  and  other  concomitant 
disharmonies  to  the  facial  outlines,  as  shown  on  the  left  of  Fig.  119.  In  this  connec- 
tion it  would  be  well  to  remember  that  in  all  normal  conditions,  when  the  features 
are  in  unconscious  repose  with  the  lips  closed,  the  teeth  are  rarely  if  ever  in  occlu- 
sion, as  the  relaxed  muscles  more  restfuUy  sustain  the  mandible  with  the  teeth 
slightly  apart. 

On  the  other  hand,  as  shown  on  the  right  of  this  figure,  if  a  supra-occlusal 
or  extrusive  malposition  of  the  teeth  or  an  open-bite  malocclusion  prevents  the 
jaws  from  coming  together  in  harmonious  relations,  the  effort  to  close  the  lips,  even 
when  the  teeth  are  not  protruded,  will  mar  the  ease  and  perfection  of  their  pose, 
with  a  frequent  obliteration  of  the  labio-mental  curve,  and  a  retraction  of  the  sur- 
face contour  of  the  chin.  Again,  it  is  very  important  in  dento-facial  orthopedia 
that  rules  which  are  acknowledged  as  the  standard  of  esthetic  beauty  with  adults, 
shovild  never  be  strictly  applied  to  the  facial  outlines  of  childhood  and  early  adoles- 
cence,  without  an  intelligent  recognition  of  the  de\eloping  influences  of  growth. 

Scope  of  the  Dento-facial  Field. — Upon  entering  the  field  of  dento-facial 
malocclusion,  it  would  be  well  for  the  student  to  first  deeply  consider  the  scope  of 
this  department.  The  possibilities  of  Dento-facial  Orthopedia  in  the  correction 
of  facial  outlines  are  confined  in  their  action  to  a  comparatively  small  area  of  that 
which  constitutes  the  framework  of  the  human  physiognomy.  The  labial  teeth 
and  alveolar  process  in  which  their  roots  are  imbedded,  and  the  incisive  or  inter- 
maxillary portion  of  the  upper  jaws,  constitute  the  principal  extent  of  the  facial 
framework,  which  it  is  possible  to  move  with  dental  regulating  appliances. 

While  a  lateral  expansion  of  arches — especially  the  upper — will  often  produce 
a  more  rounded  fullness  to  the  cheeks,  it  is  not  due  so  much  to  the  direct  support 
of  the  buccal  teeth  as  to  the  relief  of  tension  upon  the  labial  and  buccal  tissues 
that  has  followed  the  concomitant  retrusion  of  the  front  teeth  which  the  expansion 
permitted.  In  regard  to  changing  the  position  of  the  chin,  it  is  quite  rare  that  one 
has  an  opportunity  to  apply  force  at  a  sufficiently  early  age  to  retrude  the  mandible 
with  occipital  pressure,  while  a  permanent  movement  of  the  mandible  in  the 
opposite  direction,  in  the  operation  of  "jumping  the  bite,"  is  very  uncertain. 
Therefore,  we  must  place  the  chin  on  the  outside  of  the  dento-facial  area  proper, 
and  consider  it  as  one  of  the  most  prominent  landmarks  of  the  physiognomy  from 
which  to  draw  comparisons  in  diagnosis. 


CHAPTER  XXI.     DIAGNOSIS   AND   TREATMENT  185 

The  Dento-facial  Area. — The  principal  portion  of  the  human  face,  therefore, 
which  it  is  possible  to  beautify  by  moving  the  teeth  and  alveolar  process,  is  that 
formed  by  the  upper  and  lower  lips  and  the  lower  portion  of  the  nose,  bounded 
laterally  by  the  naso-labial  lines  and  below  by  the  chin.  This  is  the  "dento- 
facial  area."  (See  Fig.  121.) 

Within  this  ovoidal  area,  the  slightest  change  of  muscular  movement  expressive 
of  the  emotions  will  produce  an  apparently  marked  effect  upon  the  physiognomy. 
The  same  is  true  of  any  physical  imperfections  of  contour,  particularly  around  the 
mouth,  which  will  seem  to  change  the  entire  features.  It  is  here  that  an  inherited 
or  acquired  lack  of  symmetry  in  the  size,  shape,  or  position  of  the  teeth  and  jaws 
produces  those  marked  changes  of  facial  contour  which  characterize  the  several 
types  of  dento-facial  malocclusions.  In  nearly  all  cases  of  decided  protrusion  or 
retrusion  of  the  roots  of  the  upper  labial  teeth,  the  incisive  portion  of  the  maxillas, 
with  its  anterior  nasal  spine  and  cartilaginous  nasal  septum,  will  be  protruded  or 
retruded  in  its  dento-facial  relations.  As  this  is  the  framework  which  supports 
the  extreme  upper  portion  of  the  upper  lip  and  forms  the  base  of  the  entire  lower 
portion  of  the  nose,  with  the  naso-labial  depressions  on  either  side,  including  the 
end  and  wings  of  the  nose,  the  form  and  relative  position  of  this  facial  zone  will  be 
frequently  affected  to  a  marked  degree  in  certain  characters  of  protrusion  and 
retrusion  of  the  upper  teeth.  In  most  cases  for  youthful  patients,  this  area  is 
susceptible  of  being  changed  considerably  in  the  outlines  of  its  contour  by  a  bodily 
protruding  and  retruding  movement  of  the  teeth,  as  it  fortunately  happens  to  be 
a  fact  that  all  of  that  portion  of  the  superior  maxilla  in  which  the  incisor  teeth  are 
developed  with  its  alveolar  ridge,  will  usually  be  carried  bodily  with  the  roots  of 
the  incisor  teeth  in  a  protruding  or  retruding  phalanx  movement.  This  may  be 
largely  due  to  its  early  separate'development. 

Pjj.  p,j^  From    Gray's   Anatomy. — Gray,   in   describing   the   superior 

maxilla,  says:  "In  some  bones  a  delicate  linear  suture  may  be 
seen  extending  from  the  anterior  palatal  fossae  to  the  interval 
between  the  lateral  incisor  and  the  canine  tooth.  This  marks 
out  the  intermaxillary  or  incisive  bone.  It  includes  the  whole 
thickness  of  the  alveolar  process,  the  corresponding  part  of  the 
floor  of  the  nares,  and  the  anterior  nasal  spine,  and  contains  the 
,  r~^e   ^  sockets  of  the  incisor  teeth.        .       .       .      The  incisive  portion 

Injenor  Surface* 

is  indicated  in  young  bones  by  a  fissure  which  marks  off  a  small 
segment  of  the  palate,  including  the  incisor  teeth.  (See  Fig.  120.)  In  some 
animals  this  remains  permanently  as  a  separate  piece,  constituting  the  inter- 
maxillary bone;  and  in  the  human  subject,  where  the  jaw  is  malformed,  as  in 
cleft  palate,  this  segment  may  be  separated  from  the  maxillary  bone  by  a  deep 
fissure  extending  back  between  the  two  into  the  palate." 

A  bodily  protruding  or  retruding  movement  of  the  roots  of  the  lower  labial 
teeth  and  alveolar  ridge,  which  constitute  the  framework  that  supports  the  labio- 


186 


PART    VI.     DENTO-FACIAL   M ALOCCI.VSIOXS 


mental  area,  will  be  found  far  more  difficult  to  accomplisli  than  a  like  movement  of 
the  vippcr. 

Zones  of  Movement.  The  dento-facial  area  shown  in  Fig.  121  is  naturally 
divided  into  four  transverse  segments  or  zones  of  movement,  according  to  the 
areas  that  can  be  moved  separately  by  a  movement  of  the  crowns  or  the  roots  of 
the  underlying  teeth  and  alveolar  process.     The  zones  lying  over  the  crowns  of 

Fig.  121. 


A.  Upper  Apical  Zone 

B.  Upper  Coronal  Zone 

C.  Lower  Coronal  Zone 

D.  Lower  Apical  Zone 


the  upper  and  lower  front  teeth  are  properly  named  the  upper  and  lower  coronal 
zones,  and  those  over  the  roots,  the  upper  and  lower  apical  zones.  If  the  labial 
teeth  are  moved  bodily  backward  or  forward,  the  overlying  dento-facial  zones 
will  respond  in  proportion  to  the  movement.  In  cases  of  bodily  upper  protrusions 
or  retrusions,  the  end  of  the  nose  will  often  partake  of  the  malposition.  In  these 
cases,  a  bodily  corrective  movement  of  the  upper  labial  teeth  will  usually  straighten 
the  lines  of  the  nose,  and  thus  place  it  in  a  more  esthetic  pose. 

Remarkable  Changes  in  Facial  Expression  with  Slight  Movements 

It  is  not  often  realized  what  a  very  small  physical  change  in  the  outlines  and 
contours  of  a  face  will  produce  in  the  appearance  and  expression  of  the  entire 
physiognomy.  This  is  especially  true  of  physical  changes  within  the  dento-facial 
area  that  are  possible  to  produce  by  the  movement  of  the  teeth  and  surrounding 
alveolar  process.  This  is  diagrammatically  illustrated  in  Fig.  122,  which  shows  the 
correction  of  the  common  upper  protrusion.  The  outlines  of  the  two  faces  on  the 
left  are  drawn  exactly  alike,  except  that  which  pertains  to  the  tip  of  the  nose  and 
upper  lip,  between  the  two  parallel  lines  and  in  front  of  the  vertical  one.  The 
exact  amount  of  this  difference  in  the  two  faces  is  seen  on  the  right.  This  illus- 
trates how  a  very  slight  and  easily  possible  change  in  the  facial  outlines  will  at 
times  seem  to  change  the  entire  physiognomy  and  expression  of  the  face,  and  how 
also  in  an  artistic  practice  of  dento-facial  orthopedia,  many  apparently  wonderful 
and  even  unbelievable  corrections  are  so  frequently  accomplished.     It  is  not  so 


CHAPTER  XXL    DIAGNOSIS  AXD   TREATMENT  187 

much  because  the  physical  change  in  the  actual  measurement  of  the  framework  is 
great,  as  it  is  that  slight  movements  of  facial  contours,  if  produced  at  the  proper 
points,  will  bring  about  remarkable  esthetic  results.   It  shows,  moreover,  the  possi- 

FiG.  122. 


bilities  of  orthodontia  when  one  has  arrived  at  a  true  conception  of  artistic  rela- 
tions in  determining  the  character  and  type  of  dento-facial  malocclusions,  and  the 
movements  demanded  for  their  most  perfect  correction. 


Fig.  123. 


This  principle  is  further  illustrated  in  the  diagrammatical  drawings  under 
Fig.  123.  Like  the  former  illustration,  the  two  faces  on  the  left  are  drawn  exactly 
alike  in  every  particular,  except  a  slight  change  in  the  profile  outline  of  the  upper 


188 


PART    17.     DEM'O-FACIAL   M AI.OCC lASIONS 


lip  and  the  cud  uf  the  nose.  The  amount  oi  dillerence  in  the  facial  outlines  of  the 
two  faces  on  the  left  is  shown  on  the  right,  which  illustrates  how  a  very  little 
depression  of  tlie  central  features  of  the  physiognomy,  shown  in  the  first  figure, 
will  produce  the  effect  of  prognathism  of  the  lower  jaw.  If  the  cross  lines  of  these 
figures  were  removed,  one  would  hardly  believe  that  the  harmonizing  effect  in  the 
central  face  was  not  partly  produced  by  retruding  the  outlines  of  the  lower  lip 
and  chin,  or  that  it  had  been  accomplished  with  so  little  change  as  that  shown  on 
the  right.  This  change  is  exactly  that  which  may  be  accomplished  in  any  case 
under  eighteen  years  of  age,  with  l)odily  labial  force  properly  applied  to  the  upper 
front  teeth. 

Again,  force  may  be  applied  so  as  to  niove  any  one  of  the  dento-facial  zones 
mainly,  or  it  may  protrude  one  zone  and  at  the  same  time  retrude  the  other. 
These  principles  within  the  possibilities  of  force,  are  of  the  greatest  importance 

Fig.  124. 


in  the  esthetic  correction  of  facial  outlines,  and  are  among  the  main  principles  of 
the  science  which  have  tended  most  to  raise  this  branch  of  dentistry  above  the  ordi- 
nary methods  of  orthodontia  in  which  the  crowns  of  the  teeth  alone  are  moved. 

As  a  part  of  the  training  in  facial  diagnosis,  and  also  as  an  education  in  the 
possibilities  of  practice,  examine  carefully  each  one  of  the  physiognomies  in  Fig. 
124,  which  represent  the  correction  of  a  full  upper  protrusion  and  a  full  upper 
retrusion.  Give  attention  first  to  the  original  conditions  as  shown  by  the  facial 
casts  on  the  left.  Please  note  that  the  chin  and  lower  lip  in  both  these  cases  are 
in  normal  pose,  or  nearly  so,  in  relation  to  the  unchangeable  area.    What  appears 


CHAPTER  XXI.     DIAGNOSIS  AND   TREATMENT  189 

to  be  a  deficient  chin  in  tlie  upper  case,  and  a  too  prominent  one  in  the  lower,  is 
due  to  a  visual  error  caused  by  the  immediate  malrelations  of  the  upper  lip.  If 
the  chin  and  lower  lip  are  in  perfect  dento-facial  harmony,  the  whole  fault  must 
lie  with  the  upper,  which  is  true  of  these  cases. 

The  upper  figures  show  the  progressive  facial  stages  of  treatment  in  a  case 
of  upper  bodily  protrusion,  which  is  one  of  the  characteristic  types  of  Division  2, 
Class  II.  At  its  beginning  stage,  as  shown  on  the  left,  the  fact  that  the  naso-labial 
depressions  at  the  wings  of  the  nose  are  obliterated,  the  end  of  the  nose  slightly 
protruded,  and  the  upper  part  of  the  upper  lip,  or  apical  zone,  is  protruded  in  pro- 
portion to  the  coronal  zone,  shows  that  perfect  correction  can  only  be  accomplished 
by  a  bodily  lingual  movement  of  the  upper  labial  teeth  and  surrounding  alveolar 
process.  This  type  of  malocclusion  always  demands  the  extraction  of  the  first 
premolars. 

The  lower  figures  show  the  progressive  facial  stages  of  treatment  in  a  case 
of  upper  bodily  retrusion,  which  is  one  of  the  characteristic  types  of  Division  1, 
Class  III.  At  its  beginning  stage,  as  shown  on  the  left,  the  fact  that  the  naso- 
labial depressions  at  the  wings  of  the  nose  are  deepened,  the  end  of  the  nose  re- 
truded,  and  the  apical  zone  of  the  upper  lip  retruded  in  proportion  to  the  coronal 
zone,  shows  that  true  correction  can  only  be  accomplished  by  a  bodily  labial  move- 
ment of  the  upper  labial  teeth  and  entire  intermaxillary  process. 

The  central  profiles  in  Ijoth  these  cases  were  made  after  the  crowns  alone 
had  been  moved  lingually  in  the  one  case,  and  labially  in  the  other.  It  will  be  seen 
by  examining  the  intermediate  stages  of  the  operation,  that  the  upper  apical  facial 
zones  in  both  cases  were  practically  unchanged ;  in  fact  the  original  protrusion  and 
retrusion  along  the  tipper  portion  of  the  upper  lips  seem  increased. 

In  the  first  stage  of  the  protruded  case,  the  lingually  directed  force  was  applied 
at  the  gingival  margins  of  the  upper  labial  teeth,  with  the  hope  that  this  would 
correct  the  facial  outlines,  but  it  was  found  that  this  aft'ected  only  the  coronal 
zone  and  brought  into  more  pronounced  evidence  the  protruded  condition  of  the 
apical  zone ;  a  condition  which  is  not  always  at  first  discerned  in  the  diagnosis  of 
pronounced  upper  protrusions.  Nor  is  there  any  special  loss  of  time,  as  the  bodily 
lingual  movement  of  the  apical  ends  of  the  roots  is  only  a  continuation  of 
the  lingual  movement  of  the  coronal  portion  of  the  roots  accomplished  in  the 
first  stages. 

In  regard  to  the  second  case,  it  is  frequently  necessary  to  first  move  the  re- 
truded upper  crowns  from  their  inlocked  malpositions  with  the  lowers,  and  occa- 
sionally align  them  before  it  is  possible  to  properly  place  the  bodily  movement 
apparatus.  This  inclination  movement  of  the  crowns  corrected  the  coronal  facial 
zone  without  aft'ecting  in  the  least  the  apical  zone,  as  can  be  seen  by  the  interme- 
diate facial  cast. 

The  profiles  on  the  right  were  made  after  a  bodily  lingual  movement  of  the 
roots  had  been  performed  in  the  upper  case,  and  a  bodily  labial  movement  in  the 


190  PART   VI.    DENTO-FACIAL  MALOCCLUSIONS 

lower  case,  with  a  fairly  perfect  correction  of  the  facial  outlines.  Note  the  changes 
which  took  place  in  the  two  entire  vipper  dento-facial  zones,  even  to  the  ends  of 
the  noses;  this  shows  that  the  upper  apical  and  coronal  zones  of  any  youthful 
case  may  be  moved  separately,  together,  or  in  the  opposite  directions,  with  an 
equal  probability  of  success.  Note  also  that  the  chin  and  lower  lip  in  both  these 
cases  remained  in  their  original  positions  in  relation  to  the  unchangeable  area. 

As  one  advances  more  deeply  into  this  subject  of  facial  diagnosis  and  treatment 
from  a  clinical  standpoint  of  practice,  he  realizes  the  great  possibilities  of  ortho- 
dontia in  correcting  and  beautifying  every  face  within  a  reasonable  limit  of  age, 
whose  facial  outlines  are  marred  and  more  or  less  deformed  by  malpositions  of  the 
teeth.  Heretofore,  when  only  the  crowns  of  the  teeth  were  moved,  these  possibil- 
ities were  greatly  limited  in  extent,  but  now,  when  every  dento-facial  zone  can  be 
moved  labially  or  lingually,  separately  or  together,  it  places  dento-facial  orthopedia 
on  the  highest  possible  artistic  plane  where  its  art  workers  are  dealing  with  human 
flesh  and  bones  instead  of  canvas  and  marble.  In  no  treatment  are  these  possibil- 
ities more  strongly  emphasized  than  in  instances  where  the  upper  apical  zone  is 
moved  in  a  labial  or  a  lingual  direction  and  at  the  same  time  the  coronal  zones 
are  moved  in  the  opposite  direction.  (See  Types  of  Class  II,  Chapters  XXXVI 
and  XXXVII.) 

In  one  of  these  cases  the  upper  part  of  the  upper  lip,  or  apical  zone,  was  in  a 
retruded  position  with  deepened  naso-labial  lines.  In  the  other,  these  conditions 
were  reversed  with  flaring  nostrils  and  complete  obliteration  of  the  naso-labial 
lines.  In  both  cases  the  buccal  occlusion  was  that  of  Class  II.  As  shown  by  the 
finished  facial  and  dental  casts,  they  were  beautifully  corrected  as  described. 

The  Dento-Facial  Outlines  in  Diagnosis 

In  the  correction  of  all  malocclusions,  the  facial  outlines  should  be  regarded 
as  the  main  guide  in  determining  the  proper  treatment.  They  point  the  course 
to  be  pursued,  and  the  special  character  of  movements  in  the  correction  of  the 
occlusion  and  alignment  of  the  teeth  to  obtain  the  most  perfect  dental  and  facial 
results  for  the  individual.  Even  a  casual  artistic  examination  and  comparison  of 
the  occlusion  and  facial  outlines  of  cases  in  practice  will  soon  teach  the  futility  of 
depending  wholly  upon  the  buccal  occlusion,  or  the  facial  outlines  alone,  in  de- 
termining their  character  and  treatment.  To  illustrate  this,  examine  the  dental 
and  facial  casts  of  three  diametrically  different  facial  characters  of  malocclusion 
in  Class  I,  shown  in  Fig.  125. 

In  characters  similar  to  each  of  these  cases,  the  buccal  occlusions  may  be 
absolutely  normal,  and  yet,  as  can  be  easily  determined  by  diagnosis,  the  case  on 
the  left  is  an  upper  protrusion,  caused  by  the  malrelations  of  the  labial  teeth  due 
to  thumb-sucking;  that  in  the  middle  is  an  upper  retrusion  due  to  inhibited  in- 
cisive maxillary  development;  and  that  on  the  right  is  a  bimaxillary  protrusion 
due  to  heredity. 


CHAPTER  XXI.    DIAGNOSIS  AND   TREATMENT 


191 


In  Classes  II  and  III,  there  will  also  be  found  quite  different  characters  and 
demands  of  treatment,  though  they  will  have  the  same  disto-mesial  occlusal 
malrelations  of  the  buccal  teeth.  This  may  be  illustrated  by  a  careful  examination 
of  the  beginning  facial  and  dental  casts  of  five  cases  in  practice  from  Class  II, 
shown  in  Fig.  126.  The  lower  buccal  teeth  in  all  these  cases  are  in  full  distal  mal- 
interdigitating  occlusion  in  relation  to  the  uppers,  and  yet  their  dento-facial  diag- 
noses are  briefly  as  follows:  Case  A  is  an  upper  coronal  protrusion.  Case  B  is  an 
upper  bodily  protrusion.      Case  C  is  an  upper    coronal    protrusion    and    lower 

Fk;.  I'J.'i. 


bodily  retrusion.      Case  D  is  an  upper  coronal  protrusion  and  upper  apical  retru- 
sion.    Case  E  is  a  lower  bodily  retrusion. 

Before  a  formal  consideration  of  the  principles  of  dento-facial  diagnosis  of 
malocclusion,  according  to  Classes,  it  would  be  well  for  the  student  to  remember 
that  every  one  of  the  so-called  tmclassified,  or  locally  caused  characters,  when 
regarded  individually  in  a  clinical  examination  at  the  chair,  must  all  fall  into  one 
or  the  other  of  the  three  Classes,  in  accord  with  the  buccal  occlusion  that  is  found. 
Therefore,  in  a  case  which  presents  for  treatment,  if  it  seems  to  be  mainly  charac- 
terized by  some  special  form  of  irregularity,  it  is  important  to  first  determine  the 
Class  to  which  the  case  belongs,  by  a  careful  examination  of  the  buccal  occlusion, 
particularly  the  first  molars,  and  then  by  a  comparison  of  the  different  zones  of 
the  dento-facial  area  with  the  unchangeable  and  main  portions  of  the  face.  The 
Division  of  the  Class  to  which  the  case  belongs  will  at  once  be  apparent.  This  is 
really  necessary  as  a  first  guide  to  correct  treatment. 


192 


I'AKT    VI.     l)i:\T()-J-AC/.\/.    MAI.OCCLLS/OXS 


Wliile  there  are  doubtless  many  who  will  arrive  at  correct  conclusions  in  diag- 
nosis through  natural  artistic  discernment  (See  "Art,"  Chapter  I),  their  channels 
of  subconscious  thouglit,  if  intelligently  interpreted,  would  amount  to  about 
the  same  thing.  Nor  does  it  relieve  us  of  the  fact  that  the  great  majority  of  stu- 
dents require  well  defined  rules  in  a  jjroceeding  of  which  they  have  little  or  no 
knowledge. 

Fig.  1-2(1. 


Observation  Training. — In  training  the  mind  to  a  fuller  appreciation  of  the 
needs  of  this  department,  one  cannot  do  better  than  to  study,  unobtrusively,  the 
faces  one  meets  in  suburban  cars  and  local  transits  of  a  large  city.  In  a  face  under 
observation,  note  the  general  character  and  relations  of  the  various  parts  of  the 
principal  features,  or  unchangeable  area,  shutting  out  for  the  time  the  dento-facial 
area.  Note  the  relative  position  and  pose  of  the  chin,  with  the  malar  prominences, 
forehead,  bridge  of  the  nose,  etc.  Then  turn  to  the  dento-facial  area,  or  that 
portion  of  the  physiognomy  that  it  is  possible  to  change  in  dental  orthopedia — 
its  general  and  localized  relations  from  aii  esthetic  standpoint.  Compare  the 
outlines  of  the  dento-facial  zones  with  each  other,  and  with  the  adjoining  areas 
of  the  physiognomy  outside  oi  this  sphere  of  possible  influence.  Note  first:  the 
character  and  shape  of  the  chin  and  its  relation  to  the  lower  lip.  Do  the  lines  of 
the  labio-mental  area  form  a  graceful  and  concave  curve  to  the  border  of  the  lip, 
or  are  they  abnormally  deep  with  pointed  chin,  or  straight,  with  character  lacking.'' 
Second :  note  the  antero-posterior  relations  of  the  upper  and  lower  lips  to  each  other, 


CHAPTER   XXI.     DIAGSOSIS  AXD   TREATMENT  193 

the  lips  in  repose  and  in  talking  and  laughing;  do  they  close  with  ease,  oi"  with  a 
muscular  effort?  Is  the  natural  parting  of  the  lips  even  with  the  occlusal  plane  of 
the  teeth,  or  does  the  lower  lip  lap  over  the  occlusal  ends  of  the  upper  incisors? 
Is  this  due  to  a  short  tipper  lip,  or  to  a  supra-occlusal  malposition  of  the  upper 
labial  teeth?  Third:  note  the  shape  and  relations  of  the  upper  lip.  In  its  per- 
pendicular lines,  is  it  slightly  concave,  as  it  should  be,  or  is  it  straight  or  convex? 
Over  the  incisive  area,  does  it  gracefully  curve  with  a  slight  deepening  of  the  naso- 
labial lines  where  it  joins  the  cheeks?  Or  is  the  entire  upper  lip  protruded,  with  a 
partial  or  complete  obliteration  of  the  naso-labial  lines  and  with  that  peculiar 
prominence  of  the  middle  features  which  produces  the  effect  of  a  retruded  lower 
denture  and  mandible?  Or  is  the  entire  upper  lip  retruded,  with  an  abnormal 
deepening  of  the  naso-labial  lines  at  the  wings  of  the  nose,  which  produces  the  effect 
of  lower  prognathism? 

Practical  Diagnosis. — When  these  oft-repeated  observations  are  put  into 
practical  use  in  contemplating  the  treatment  of  a  dental  irregularity,  the  first 
thought  of  the  operator  will  naturally  be  directed  to  the  physiognomy  in  an  in- 
telligent and  critical  observation  of  the  temperament,  age,  development,  the  char- 
acter of  the  facial  outlines,  then  the  character  of  the  occlusion,  especially  that  of 
the  first  molars,  and  finally  the  probable  causes. 

This  may  usually  be  accomplished  without  special  display,  or  without  occupying 
more  time  than  would  be  necessary  for  examining  the  teeth.  In  fact,  it  may  require 
but  a  glance  to  show  that  the  case  does  not  belong  to  any  of  the  Classes  of  Pro- 
trusion or  Retrusion,  and  that  you  may  expect  to  find  it  characterized  by  one  or 
more  of  the  locally  caused  malpositions  of  Class  I. 

If  there  are  no  marked  imperfections  in  the  contours  and  outlines  of  the  dento- 
facial  area  in  relation  to  its  difterent  zones  and  the  rest  of  the  features,  the  disto- 
mesial  relations  of  the  buccal  occlusion  will  usually  be  found  normal,  or  nearly  so, 
providing  all  the  permanent  teeth  forward  of  the  first  molars  have  erupted.  The 
teeth  may  be  decidedly  malposed,  malturned,  and  in  fact  so  irregular  in  their 
alignment,  that  their  correction  may  seem  to  be  impossible  or  inadvisable  without 
extraction.  This  is  a  consideration  which  should  never  seriously  arise  except  in 
those  rare  cases  when  one  is  positively  sure  their  alignment  will  produce  a)i  objection- 
able facial  protrusion;  aiid  even  then,  if  it  is  for  child  ret/  iDider  twelve  years  of  age,  a 
normal  occlusion  ivith  a  somewhat  protruded  mouth  will  comim>nly  correct  itself  in  the 
subsequoit  growth  ami  devclopnwnt  of  other  parts. 

If  permanent  teeth  are  missing  through  injudicious  extraction,  impaction,  or 
extinction  of  tooth  germs,  the  teeth  back  of  these  spaces  will  usually  drift  forward, 
changing  the  occlusion  from  what  otherwise  would  have  been  normal.  The  local 
cause  of  this  malrelation  is  not  difficult  to  determine,  and  in  nearly  all  cases  de- 
mands a  restoration  of  the  buccal  teeth  to  normal  occlusal  positions. 

If,  however,  the  case  is  seen  to  belong  to  the  dento-facial  division,  it  may 
require  a  far  more  careful  observation,  extending  through  several  sittings  to  deter- 


194  PART    VI.     DENTO-FACfAL   M A f. OCCLUSIONS 

mine  the  special  division  of  type  to  which  it  belongs.  This  study  may  demand  a 
full  acquaintance  with  all  the  relations — the  teeth  to  each  other,  their  malpositions 
and  occlusion,  the  relation  which  they  bear  to  the  facial  contours,  and  the  esthetic 
relation  which  different  zones  of  the  dento-facial  area  bear  to  each  other  and  to 
other  portions  of  the  physiognomy. 

In  the  study  of  a  physiognomy  with  the  view  of  determining  its  particular 
facial  disharmony,  and  the  Class,  Division,  and  Type  to  which  a  case  belongs,  as  a 
guide  to  the  general  movement  demanded  for  its  correction,  the  head  of  the  patient 
should  be  in  an  upright  position,  somewhat  in  a  line  with  that  of  the  observer,  and 
the  face  studied  from  different  angles,  in  repose,  and  in  action.  In  the  absence 
of  the  patient,  the  facial  cast  will  be  of  great  value  for  this  purpose,  and  also  for 
comparison  during  the  progress  and  finish  of  the  work,  as  are  the  original  dental 
casts.  A  cursory  examination  of  the  dentures,  particularly  the  buccal  occlusion 
on  both  sides,  will  give  one  a  line  on  determining  the  character  of  the  dento- 
facial  relations. 

While  you  are  looking  at  a  profile  in  repose,  the  first  thing  to  determine  is  the 
relative  position  of  the  chin  to  the  unchangeable  area  of  the  physiognomy,  the 
landmarks  of  which  are,  the  forehead,  malar  prominences,  and  bridge  of  the  nose. 
If  the  position  of  the  chin  is  in  proper  relation,  and  the  lower  lip  is  well  posed,  it 
indicates  that  any  movement  of  the  teeth  of  the  lower  denture  to  correct  mal- 
positions or  malrelations,  should  be  performed,  if  possible,  without  changing  the 
general  labio-lingual  relations  of  the  lower  front  teeth.  It  may  be  necessary  to 
widen  the  lower  arch  to  correct  crowded  malalignments  of  the  lower  front  teeth, 
or  it  may  be  needful  to  move  the  lower  buccal  teeth  distally  to  correct  cuspid 
maleruptions  caused  by  premature  loss  of  deciduous  teeth,  etc. 

If  the  chin  and  lower  lip — with  the  graceful  labio-mental  curve — are  in  harmony 
with  each  other,  it  means  that  the  lower  labial  teeth  are  in  normal  mandibular 
relations ;  and  this  is  true  also  of  the  entire  lower  denture  if  the  back  teeth  are  not 
materially  irregular.  Now,  if  the  said  lower  facial  outlines  are  in  esthetic  relations 
to  the  principal  features  of  the  physiognomy,  the  facial  outlines  of  the  upper,  and 
the  occlusion  of  the  buccal  teeth  must  at  once  determine  the  Class  to  which  the  case 
belongs,  and  the  general  course  of  treatment.  These  rules  and  their  relations  are 
applicable  in  all  characters  of  dento-facial  malocclusion. 

Whatever  the  complication,  the  position  of  the  chin  and  lower  lip  in  relation 
to  esthetic  facial  outlines  should  always  be  regarded  as  one  of  the  main  guides  to 
treatment.  Thus,  through  this  same  system  of  diagnosis,  each  one  of  the  Divisions 
and  Types  of  the  three  Classes  of  Malocclusion  may  be  intelligently  determined, 
and  its  general  treatment  outlined. 

It  will  also  be  observed  that  the  disto-mesial  relations  of  buccal  occlusion 
signify  only  the  Class  in  which  the  case  belongs,  and  that  the  relation  of  the  dento- 
facial  zones  to  each  other  and  to  the  rest  of  the  features  signifies  the  Division  and 
Type  which  stands  for  the  real  character  and  indicates  the  treatment. 


CHAPTER  XXr.    DIAGNOSIS  AND   TREATMENT  195 

Principles  of  Diagnosis,  According  to  Classes 

Class  I. — In  the  diagnosis  of  dento-facial  malocclusions,  if  the  disto-mesial 
relation  of  buccal  occlusion  is  normal,  or  nearly  so,  the  case  evidently  belongs 
to  that  great  Division  1,  of  Class  I,  which  is  composed  of  malpositions  that  arise 
from  local  causes.  When  they  occur  in  this  Division,  therefore,  the  visual  treat- 
ment should  consist  in  placing  the  dentures  in  normal  occlusion.  But  on  the  other 
hand,  it  should  be  remembered  that  in  Division  2  of  this  Class — which  refers  to 
Bimaxillary  Protrusion  and  Retrusion  which  arise  from  some  form  of  heredity — 
the  buccal  teeth  are  not  only  in  normal  disto-mesial  relation,  but  the  entire  den- 
tures are  often  in  absolute  normal  occlusion.  In  these  characters  of  dento-facial 
malocclusion,  the  facial  outlines  alone  are  the  guides  for  determining  the  Division 
to  which  they  belong,  and  the  treatment  demanded. 

As  has  been  previously  stated:  The  original  plan  or  inherited  anatomic  posi- 
tion of  the  dentures  in  a  very  large  proportion  of  the  human  race  is  that  of  normal 
occlusion  with  dento-facial  harmony;  consequently,  the  niany  local  causes  of  mal- 
occlusion have  a  very  much  larger  field  to  attack  in  Class  I  occlusions  than  in  the 
inherited  disto-mesial  malocclusions  of  Classes  II  and  III.  In  Class  I,  therefore, 
we  find  almost  every  variety  of  malocclusion  which  arises  from  local  causes.  Often 
two  or  more  local  causes  working  at  the  same  time  or  following  each  other  in  se- 
quence, have  contributed  toward  producing  the  various  results. 

Of  course,  these  same  local  causes  quite  freely  arise  in  connection  with  inherited 
disto-mesial  malocclusions  of  Classes  II  and  III,  and  will  be  found  to  produce 
their  characteristic  stamp,  though  varied  more  or  less  by  the  original  condition. 
Thus  we  find  in  every  disto-mesial  malrelation  of  buccal  occlusion,  crowded  mal- 
alignments, impacted  teeth,  maleruption  of  cuspids,  and  in  fact  every  malposition 
which  arises  from  local  causes,  though  not  so  frequently  as  in  Class  I. 

There  is,  however,  one  exception  to  this  rule  relative  to  open-bite  malocclusion, 
which  is  found  most  frequently  in  connection  with  Class  III,  because  its  local 
cause  is  mainly  that  which  produces  many  of  the  general  malocclusions  of  that 
Class.  But  in  the  main,  the  foregoing  rule  holds  good,  which  shows  why  so  large 
a  proportion  of  locally  caused  irregularities  arise  in  Class  I,  and  also  why  these 
often  very  pronounced  characters  cannot  be  assigned  individually  to  any  one  of  the 
three  Dento-occlusal  Classes,  even  though  they  frequently  dominate  the  entire 
irregularity. 

As  it  is  a  fact,  however,  that  locally  caused  malpositions  arise  so  extensively 
in  this  Class,  it  has  been  deemed  advisable  for  the  teaching  purposes  of  this  work  to 
place  under  Division  1  those  special  malocclusions  of  a  dento-facial  character 
which  are  most  frequently  found  in  this  Class.  The  rest  of  the  locally  caused  cliar- 
acters  will  be  found  in  "Unclassified  Malocclusions"  in  Part  VII.  This  arrange- 
ment presents  an  opportunity  to  place  the  diagnosis  and  technic  treatment  of  four 
of  the  most  dominant  types  of  this  group  within  the  domain  of  Classified  Mal- 
occlusions where  they  can  be  studied  and  compared  in  closer  proximity  to  similar 


196 


/MA'7'    17.     DhlNTO-FACIM.    M ALOCCI.L'SIONS 


conditions  found  in  dlher  Classes,  i.  e.,  Maleruplion  of  Cuspids,  Tlnunb-sucking 
Protrusions,  Lateral  Malocclusions,  and  Open-bile  Malocclusions. 

For  the  same  reason,  retrusion  of  the  upper  incisors  and  intermaxillary  process 
due  to  inhibited  development,  when  occurring  with  normal  occlusions,  is  strictly 
a  type  of  Division  1  of  this  Class,  but  in  its  practical  treatment,  it  is  described 
in  this  work  in  Class  III,  because  of  its  similarity  in  facial  character  to  nearly 
all  the  types  of  that  Class,  and  because  it  gives  an  o])p()rtunity  in  teaching,  to  draw 
sharp  lines  of  comparison  and  treatment. 

Class  II. — There  are  probably  no  two  malocclusions  which  so  decidedly  differ 
in  their  demands  of  treatment,  as  Divisions  1  and  2  of  Class  II,  notwithstanding 
the  fact  that  the  occlusion  of  the  teeth  is  the  same.  Division  1  is  mainly  character- 
ized dento-facially  by  a  retruded  malposition  of  the  lower  denture,  and  Division  2 
is  mainly  characterized  by  a  protruded  malposition  of  the  upper.  Between  extreme 
cases  of  these  two  Divisions  will  be  found  every  reciprocal  gradation  of  dento- 
facial  malocclusion,  the  composite  of  which  is  a  partial  retrusion  of  the  lower  den- 
ttire  and  a  partial  protrusion  of  the  upper.  Tlie  comm()n  treatment,  imder  the 
Angle  teaching,  was  unfortunately  based  almost  solely  upon  the  malocclusion  of 
the  buccal  teeth  which  characterizes  this  Class,  and  consisted  principally  in  a  disto- 

Fic    127. 


mesial  shifting  of  the  dentures  to  a  normal  occlusion  ///  \ 
every  case.  During  later  years,  there  has  been  an  effort  I 
on  the  part  of  those  who  persisted  in  following  this  system  [ 
to  place  the  greatest  movement  on  the  denture  which 
needed  it  the  most.  This,  with  the  abnormal  expansion 
of  the  upper  arch,  in  tipper  protrusion,  resulting  no  doubt 
in  an  improvement  of  the  facial  outlines,  has  led  many  to 
imagine  they  were  practicing  the  true  principles  of  ortho- 
dontia. Let  us  hope  that  the  futility  of  this  effort  will 
be  seen  by  all  orthodontists  in  the  correction  of  pro- 
nounced upper  protrusions. 

In  both  of  these  divisions,  the  upper  denture  in  a  masticating  closure  is  about 
the  width  of  a  cusp  in  front  of  a  normal  occlusion  in  relation  to  the  lower,  and 


CHAPTER   XXI.     DIAGXOSIS  AND   TREATMENT  197 

with  the  chin  in  normal  dento-facial  relation.  Therefore,  if  the  upper  lip  is  not 
protruded,  as  in  Type  A,  Division  1,  the  lower  denture  must  be  retruded  in  relation 
to  a  normalh-  posed  chin  and  the  rest  of  the  facial  framework,  to  the  full  extent 

Fig.  128. 


of  the  buccal  malocclusion.  This  is  proven  by  the  re- 
truded position  of  the  lower  lip  and  deep  labio-mental 
depression  in  relation  to  the  chin  and  all  other  parts. 
It  is  somewhat  rare,  however,  to  find  a  case  with  this 
character  of  buccal  occlusion  in  which  the  upper  lip  is 
not  even  slightly  protruded  in  relation  to  the  main  or 
unchangeable  features  of  the  physiognomy.  Figs.  127  and 
128  quite  fully  illustrate  this  type.  In  viewing  the  begin- 
ning facial  outlines  of  these  faces,  the  inclination  to  com- 
pare the  position  of  the  upper  lip  with  the  lower  instead 
of  the  other  features,  will  produce  the  effect  of  an  upper 

protrusion,  when  perhaps  it  is  purely  a  lower  retrusion  or  what  is  most  commcjn 
of  this  Type,  a  very  slight  upper  protrusion,  as  in  Fig.  127. 

In  Division  2,  the  lower  lip  and  chin  are  in  normal  dento-facial  pose,  which 
is  characterized  by  a  graceful  labio-mental  curve,  and  shows  that  the  lower 
denture  is  in  normal  relation  to  a  perfectly  posed  mandible.  Therefore,  if  the 
upper  denture  is  the  width  of  a  cusp  in  front  of  a  normal  occlusion  with  the 
perfectly  posed  lower,  the  upper  denture  must  be  protruded  to  the  full  extent  of 
the  buccal  malocclusion.  This  is  readily  evidenced  by  the  protruding  lip  in  rela- 
tion to  the  other  features.    See  Fig.  128. 

With  the  same  mesial  malocclusion  of  the  lower  buccal  teeth,  which  charac- 
terizes this  entire  Class  II,  there  will  be  found  every  reciprocal  gradation  of 
dento-facial  malocclusion  which  lies  between  Divisions  1  and  2.  In  addition  to 
this,  there  are  certain  complications  which  arise  in  both  Divisions  1  and  2,  and 
which  are  placed  in  the  practical  treatment  under  "Concomitant  Characters," 
where  a  full  description  and  diagnosis  will  be  found. 


198  .         PART   VI.    DENTO-FACIAL   MALOCCLUSIONS 

Class  III  is  characterized  dentally  by  a  mesial  malocclusion  of  the  kjwer  buccal 
teeth — the  lower  labial  teeth  closing  in  front  of  the  upper.  Facially,  it  is 
characterized  by  an  abnormal  retrusion  of  the  upper  dento-facial  zones  with 
deepened  naso-labial  lines,  and  often  with  a  slight  abnormal  retrusion  of  the 
end  of  the  nose.  Malocclusions  of  this  Class  are  nearly  as  frequent  in  occurrence 
as  those  of  Class  II,  and  in  their  most  marked  characters  produce  facial 
deformities  that  are  quite  as  unpleasant  in  appearance.  Like  Class  II,  also, 
they  present  a  number  of  important  and  interesting  Divisions  and  Types  which 
demand  the  most  careful  and  intelligent  comparisons  of  dental  and  facial  relations 
to  determine  their  real  character  and  the  treatment  demanded  in  their  correction. 


CLASS  I 

NORMAL   DISTO-MESIAL   OCCLUSION 


Table  of  Divisions  and  Types 
DIVISION    1:     LOCALLY   CAUSED   DENTO-FACIAL   MALOCCLUSIONS 
Type  A:    unilateral  maleruption  of  cuspids 
Type  B:    bilateral  maleruption  of  cuspids 
Type  C:    bilateral  maleruption  of  cuspids  in  class  ii 
Type  D:  protrusion  of  upper  front  teeth 
Type  E  :    retrusion  of  upper  front  teeth     (See  Division  2,  ciass  iid 
Type  F:    lateral  malocclusion 
Type  G:  open-bite  malocclusion 

DIVISION   2:     EIMAXILLARY   PROTRUSION  AND   RETRUSION 


CLASS  I 


CHAPTER   XXII 

PRINCIPLES   OF   DIAGNOSIS   IN  MALERUPTION   OF   THE   CUSPIDS 

Diagnosis. — Tlie  most  frequent  (lento-facial  irregvilarity  of  the  teeth  is  that 
which  is  characterized  l.)y  a  Malcruption  of  the  Cuspids;  and  since  it  arises  from 
various  local  causes,  it  will  be  found  in  connection  with  every  disto-mesial  mal- 
relation  of  the  buccal  teeth.  In  other  words,  it  will  be  found  at  times  characteriz- 
ing every  one  of  the  three  Classes  of  Malocclusion.  It  arises  far  more  frequently 
in  Class  I — as  in  all  locally  caused  malocclusions — because  in  inherited  normal 
occlusions  of  the  teeth,  there  is  a  far  larger  field  for  local  causes  to  attack  than  in 
inherited  malocclusions  of  the  buccal  teeth. 

Fig.  129. 


The  most  common  characteristic  is  that  of  a  labial  maleruption  of  the  upper 
ctispids,  and  occasionally  upon  one  side  alone,  as  shown  in  Fig.  129.  While  this 
condition  will  frequently  be  found  with  both  the  upper  and  lower  dentures,  it  far 
more  commonly  occurs  with  the  uppers  alone.  If  in  these  cases  it  is  accompanied 
with  an  irregularity  of  the  lower,  it  will  usually  be  a  malalignment  of  the  incisors 
with  the  ctispids  more  or  less  prominent,  though  fully  erupted.  The  reason  for  the 
more  frequent  maleruption  of  the  upper  cuspids  as  compared  to  the  lower,  is  partly 
due  to  the  earlier  eruption  of  the  lower  cuspids,  which  permits  them  to  take  their 

200 


CHAPTER   XXH.     DIVTSION  1.     CLASS  I.  201 

positions  before  the  loss  of  the  deciduous  molars,  and  the  eruption  of  the  premolars. 
It  is  also  due  to  the  fact  that  the  temptation  to  prematurely  extract  the  lower 
deciduous  cuspids  to  correct  a  seeminj:,^  irre<^ularity.  does  not  arise  as  frequently 
as  with  the  upper. 

While  the  technic  correction  of  this  character  of  malocclusion,  illustrated 
in  the  following  pages,  deals  principally  with  the  upper  denture,  it  should  be 
remembered  that  the  methods  and  principles  of  movement  which  are  here  de- 
scribed, are  in  the  main  equally  applicable  to  like  conditions  upon  the  lower. 
There  are  a  number  of  complications  which  arise  in  connection  with  this  char- 
acter demanding  quite  radical  variations  in  treatment,  which  can  only  be 
determined  by  a  careful  and  intelligent  consideration  of  dental  and  dento-facial 
relations. 

Alaleruption  of  the  Cuspids  arises  so  rareh--  from  heredity,  we  may  consider  it 
as  arising  wholly  from  local  causes,  though  of  course  heredity  in  malposing  the 
disto-mesial  occlusion  of  the  buccal  teeth,  frequently  plays  an  important  part  as 
an  aid  to  the  local  cause,  increasing  the  difficulties  of  correction. 

In  a  large  majority  of  cases,  the  position  of  the  malposed  cuspids  is  caused 
b\^  the  premature  loss  of  the  deciduous  teeth,  which  permits  an  abnormal  mesial 
movement  of  the  buccal  teeth  with  more  or  less  retrusion  of  the  incisors,  partially 
or  completely  closing  the  cuspid  spaces.  If  this  cause  arises  with  the  upper  teeth 
alone,  or  only  upon  one  side,  the  approximating  lower  teeth  will  usually  be  driven 
into  malalignment.  When  this  has  occurred  with  yoking  patients  whose  inherited 
occlusion  is  normal,  there  should  be  no  hesitation  in  placing  the  teeth  in  normal 
occlusion  even  though  the  crests  of  the  cusps  have  passed  the  crests  of  the  opposing 
buccal  teeth,  and  the  spaces  for  the  cuspids  are  entirely  closed.  As  an  illustration 
of  this,  turn  to  Fig.  28,  Chapter  XII. 

In  some  instances,  the  mesial  drifting  movement  of  the  upper  buccal  teeth  will 
amount  to  a  complete  jumping  of  the  cvisps,  and  a  full  malinterdigitation,  which 
judged  from  the  malposition  of  the  teeth  alone,  might  easily  be  mistaken  for  an 
inherited  mesial  occlusion  of  the  upper  buccal  teeth,  which  would  produce  an  upper 
protrusion  if  the  cuspids  were  in  alignment. 

In  cases  of  this  character,  if  there  is  a  general  lack  of  fullness  in  the  dento- 
facial  area,  particularly  over  the  lower  coronal  zone,  showing  that  the  adult  features 
will  require  all  the  teeth  in  the  arches  to  properly  develop  the  facial  contours, 
they  should  be  placed  in  normal  occkision. 

One  can  miderstand  by  this  case,  how  a  person  may  have  a  full  coronal  upper 
protrusion  due  wholly  to  the  cfimbined  forces  of  two  local  causes,  i.  e.,  first,  the 
loss  of  deciduous  teeth  permitting  the  mesial  drift  of  the  first  permanent  molars, 
causing  a  mesial  maleruption  of  the  premolars  to  a  sufficient  extent  that  permits 
them  to  pass  the  crests  of  the  lower  premolars  into  a  final  full  malinterdigitation; 
second,  if  this  occurs  with  a  thumb-sucking  patient,  the  crowns  of  the  labial  teeth 
and  alveolar  process  will  be  forced  forward,  giving  room  for  the  perfect  eruption  and 


202  PART    VI.     DENTO-FACIAL    MALOCCLUSIONS 

alignment  of  the  cuspids,  with  a  resuh  that  may  have  all  the  dento-facial  charac- 
teristics of  the  ordinary  Type  A,  Division  2,  Class  II  case. 

Practical  Application  of  Rules 

The  following  common  examples  will  serve  to  illustrate  the  clinical  applica- 
tion of  the  main  rules  of  diagnosis  and  treatment  when  applied  to  those  mal- 
occlusions that  are  characterized  by  a  maleruption  of  the  cuspids. 

Let  us  suppose,  first,  that  the  case  in  hand  is  mainly  characterized  by  a  pro- 
nounced labial  maleruption  of  the  ugper  cuspids,  with  the  spaces  between  the  lat- 
erals and  first  premolars  nearly  or  cjuite  closed,  and  that  the  buccal  occlusion  places 
it  in  Class  I.  Then  by  following  the  rules  of  dento-facial  diagnosis,  outlined  in  the 
previous  chapter,  if  you  find  that  the  chin  and  lower  lip  are  in  esthetic  pose,  and  the 
lower  denture  is  in  normal  arch  alignment,  the  case  is  at  once  located  in  Division  1, 
as  Type  B,  in  which  correction  demands  placing  the  dentures  in  normal  occlusion 
with  no  mesial  movement  of  the  lower.    See  Fig.  28,  Chapter  XII. 

Second:  With  the  same  normal,  or  nearly  normal  buccal  occlusion,  accom- 
panied with  crowded  maleruption  of  upper  cuspids,  if  the  lower  lip  is  decidedly 
protruded  in  relation  to  a  normally  posed  chin,  the  placing  of  the  dentures  in  normal 
occlusion,  without  a  decided  and  very  inadvisable  distal  movement  of  the  lower 
denture,  would  protrude  the  upper  lip  to  the  same  degree  as  that  of  the  lower 
with  the  production  of  a  bimaxillary  protrusion,  as  in  Division  2  of  Class  I,  in 
which  perfect  correction  would  demand  the  extraction  of  two  upper  and  two  lower 
teeth — preferably  the  first  premolars — everything  else  being  ecjual.  See  Fig.  160, 
Chapter  XXIX. 

Third:  Let  us  suppose  that  with  the  same  peculiar  strongly  marked  mal- 
eruption of  the  upper  cuspids,  the  lower  buccal  teeth  are  in  distal  malocclusion, 
and  upon  an  examination  of  the  facial  outlines,  we  find  that  the  chin  and  lower 
lip  are  in  normal  pose.  The  case  in  all  probability  is  an  inherited  upper  protrusion, 
notwithstanding  the  fact  that  the  upper  lip  is  not  materially  protruded  except 
over  the  canine  area,  because  the  incisors  are  in  a  retruded  position,  closing  the 
cuspid  spaces.  If  the  upper  teeth  are  placed  in  alignment  with  no  other  movement, 
it  would  be  a  typical  upper  protrusion,  as  in  Division  2  of  Class  II.  Therefore, 
the  extraction  of  the  first  upper  premolars  is  indicated,  to  allow  the  cuspids  to  take 
their  places,  correct  the  facial  outlines,  and  leave  the  patient  with  a  perfect  inter- 
digitating  occlusion.  For  practical  treatment  of  this  character,  see  Type  C,  Divi- 
sion 1,  Class  I. 

Fig.  130  is  a  good  illustration  of  this  type.  It  belongs  to  Class  II,  as  one  can 
see  by  the  mesial  malinterdigitation  of  the  upper  buccal  teeth.  It  is  placed  in 
Class  I  to  draw  a  sharp  comparison  between  cases  in  which  locally  caused  malerup- 
tion of  the  upper  cuspids  arises  with  normal  occlusion  and  with  inherited  upper 
protrusions.  The  retruded  position  of  the  incisors  entrapping  the  cuspids  has 
prevented  the  case  from  assuming  a  typical  inherited  protrusion,  because  it  should 


CHAPTER  XX H.     DIVISIOX   1.     CLASS  I. 


203 


be  remembered  that  whenever  the  results  of  a  local  cause  arise  in  connection  with 
an  inherited  Class  II  malocclusion  of  the  buccal  teeth,  the  treatment  should  always 
be  regulated  by  the  dento-facial  character  of  its  original  inherited  state,  or  the 
state  in  which  it  would  be  if  the  front  teeth  were  placed  in  alignment. 


Fig.  130. 


Fovu-th :  With  the  same  dental  character  of  malocclusion  as  in  the  above  case, 
if  there  is  a  pronounced  retrusion  of  the  lower  lip  in  relation  to  a  normally  posed 
chin,  the  placing  of  the  upper  teeth  in  alignment  will  produce  little  or  no  upper 
protrusion,  showing  that  the  case  belongs  to  Type  A,  Division  1  of  Class  II,  where 
its  treatment  will  be  found  fully  defined. 

On  the  other  hand,  if  the  lower  lip  is  only  moderately  retruded  in  relation  to 
the  chin,  the  placing  of  the  upper  teeth  in  alignment  will  produce  a  moderate 
upper  protrusion,  as  in  Type  B  of  that  Division.  Commonly,  the  dentures  can  be 
shifted  to  a  normal  occlusion  in  these  cases  without  producing  a  disharmony 
to  the  dento-facial  outlines.  It  should  be  borne  in  mind,  however,  that  any  exten- 
sive reducive  movement  of  the  entire  upper  denture,  especially  that  of  inherited 
Types,  is  very  liable  to  be  impossible  to  retain. 

In  all  cases,  it  is  important  to  determine  whether  the  malocclusion  of  the 
buccal  teeth  is  due  to  local  or  inherent  causes.  If  from  local  causes,  and  the  disto- 
mesial  malocclusion  is  only  half  the  width  of  a  cusp,  there  should  be  no  hesitation 
in  placing  the  buccal  teeth  in  normal  occlusion  for  children,  even  after  the  eruption 
of  the  second  molars,  and  in  many  cases,  after  the  crests  of  the  cvisps  have  passed 
their  normal  boundaries,  but  always  with  a  reciprocal  disto-mesial  movement 
that  is  regulated  according  to  the  demands  of  the  facial  outlines.  On  the  other 
hand,  if  the  cause  is  heredity,  and  the  case  arises  in  practice  after  the  second  molars 
have  fully  erupted,  and  with  no  retrusion  of  the  lourr  denture  and  lower  lip  in  rela- 
tion to  the  chin,  as  in  the  case  illustrated  by  Fig.  128,  the  propriety  of  extracting 
should  be  considered  rather  than  attempt  to  retrude  all  the  buccal  teeth  one-half 
the  width  of  a  cusp  or  more  from  an  inherited  position  in  the  jaw. 


204  PART    VI.     DES TO-FACIAL    MALOCCLUSIONS 

It  must  not  be  forgotten  that  niuleruption  of  tlie  euspids  arises  in  connection 
with  every  Division  and  Type  of  Class  II,  and  that  the  treatment  of  the  case  after 
the  Type  is  determined  by  an  intelhgent  dento-facial  diagnosis,  is  exactly  the  same 
as  it  would  be  if  cuspids  were  fully  erupted  and  in  alignment. 

Fifth:  One  of  the  common  forms  of  maleruption  of  the  upper  cuspids  is  that 
which  is  characterized  by  crowded  and  contruded  malalignments,  the  entire  maxilla 
being  contracted,  with  the  dome  of  the  arch  high  and  narrow,  frequently  resulting 
in  one  of  the  forms  of  upper  retrusions  in  Class  III.  The  cause  of  this  condition 
may  usually  be  traced  to  early  diseases  of  the  naso-maxillary  sinuses,  adenoid 
vegetations,  enlarged  tonsils,  mouth-breathing,  etc.,  resulting  in  a  lack  of  normal 
development  of  the  superior  maxillary  bones.  In  some  instances,  the  effect  of  this 
condition  upon  the  facial  outlines  is  cjuite  marked,  the  upper  dento-facial  area 
being  more  or  less  retruded  with  deepened  naso-labial  lines  and  nan'owed  seating 
of  the  nostrils.  When  associated  with  open-bite  malocclusion,  which  arises  from  the 
same  cause,  the  mandible  will  freciuently  be  prognathic.  See  Figs.  212,  Chapter 
XLIII,  and  228,  Chapter  XLV. 

Particular  attention  is  called  to  these  facts  to  show  the  need  of  an  intelligent 
diagnosis,  based  upon  dento-facial  relations,  and  not  u])on  occlusion  alone  in  the 
correction  of  all  irregularities. 

Such  a  very  large  proportion  of  maleruption  of  the  upper  cuspids  arises  in 
connection  with  Class  I  occlusion,  and  from  local  causes,  demanding  a  general 
enlargement  of  the  upper  and  lower  arches  to  make  room  for  the  cuspids  and  perfect 
the  occlusion,  the  extraction  of  teeth  should  never  be  resorted  to  as  an  aid  to  the 
process  of  correction,  but  always  as  a  dernier  resort,  when  convinced  that  it  is 
demanded  for  the  greater  perfection  of  occlusion,  dento-facial  harmony,  and  final 
retention.  If  over-zealous  dentists  would  view  these  conditions  from  the  broader 
standpoint  of  future  relations,  sure  to  be  brought  about  in  the  developing  and 
enlarging  influences  of  growth,  and  consider  the  importance  of  a  normal  occlusion 
of  the  teeth  and  the  retention  and  preservation  of  means  to  that  end,  they  would 
be  rendering  the  only  true  professional  service  that  would  redound  to  their  credit 
and  the  future  good  of  their  little  patieiits.  Many  instances  can  be  shown  where  the 
injudicious  extraction  of  the  first  or  second  premolars,  or  the  first  molars,  for  young 
patients,  has  caused  a  disharmony  in  the  size  of  the  arches,  and  a  malocclusion 
impossible  to  correct  without  either  the  extraction  of  premolars  from  the  lower 
arch,  or  the  opening  of  space  on  the  upper  for  the  insertion  of  artificial  teeth. 


CHAPTER   XXIII 

Type  A,  Division  1,  Class  I 

UNILATERAL   MALERUPTION   OF  THE   CUSPIDS 

When  an  upper  cuspid  is  prevented  from  properly  erupting  because  of  a  partial 
or  complete  closure  of  its  space,  it  will  frequently  be  impossible  for  it  to  ever  align 
itself  unaided  through  the  natural  influences  of  growth,  because  of  the  general  con- 
traction of  the  arch  from  causes  that  continue  to  exert  their  influence,  even  to 
driving  the  lower  teeth  into  malalignment. 

A  unilateral  irregularity  of  this  type  is  often  more  difficult  to  correct  properly 
than  one  that  is  bilateral,  because  the  forces  on  each  side  of  the  mouth  are  not 

Fig.  131. 


reciprocal;   consequently  they  require   greater  skill   and   a   peculiar  application 
of  force  to  keep  the  arch  in  symmetrical  form. 

The  cuspid  spaces  at  times  are  entirely  closed,  principally  through  a  mesial 
drifting  movement  of  the  buccal  teeth,  and  a  partial  retrusive  and  lateral  movement 
of  the  incisors  toward  that  side,  permitted  by  the  premature  loss  of  deciduous  cus- 

FiG.  132. 


pids.  The  contraction  of  the  upper  arch  usually  contracts  the  lower,  crowding  the 
teeth  into  malalignment,  demanding  a  concomitant  enlargement  of  the  lower 
arch  with  that  of  the  upper. 

205 


20  G 


PART    VI.     DEy TO-FACIAL   MALOCCLUSIONS 


At  the  beginning  of  the  case  iUustrated  in  Fig.  131,  the  mesial  movement  of 
the  left  upper  premolars  and  molars  had  caused  the  crests  of  the  cusps  to  strike 
upon  the  crests  of  the  lowers,  while  on  the  right  side  the  teeth  were  nearly  in 
normal  occlusion.  Again,  in  Fig.  132,  is  shown  another  case  in  which  the  right  upper 
buccal  teeth  were  nearly  in  complete  mesial  malinterdigitation,  with  the  cuspid 
space  fully  closed,  while  on  the  left  side,  the  occlusion  was  nearly  normal. 

Fig.    133. 


Tf.rnai. 


Fig.  134. 


The  apparatus  shown  in  Fig.  133  is  well  calculated  for  regulating  slight  uni- 
lateral iiTegularities  of  this  character.  One  end  of  the  arch-bow,  No.  19,  rests  in 
a  buccal  T-tube  attachment  on  the  premolar,  the  distal  end  of  which  is  supported 
in  a  molar  open-tube  attachment,  the  combination  being  calculated 
to  promote  a  distal  inclination  movement  of  the  bticcal  teeth.  See 
Movable  Anchorages  in  Chapter  XV.  The  other  end  of  the  bow  is 
adjustably  fastened  with  two  nuts  to  the  left  molar  tube  attach- 
ment. The  bow  carries  a  fi.xed  lug-tube  "a"  soft-soldered  at  a 
point  to  engage  with  an  open-tube  attachment  on  the  lateral  band. 
Instead  of  the  lug  "a"  the  thread  of  the  bow  may  extend  mesially 
to  carry  another  nut — as  in  the  disassembled  apparatus — to  engage 
with  the  lateral  through  the  medium  of  sliding  tubes,  as  shown  in 
Fig.  134.  This  combination  permits  lessening  the  direct  stress  upon  the  lateral  by 
unscrewing  the  lug-nut  "b"  with  a  distribution  of  the  protruding  force  of  the  bow 
upon  all  the  incisors. 


CHAPTER  XXIII.     TYPE  A.     DIVISIOX   1.     CLASS  I. 


207 


The  incisor  bands,  with  hook  or  open-tube  attachments,  clasp  the  bow  to  force 
the  teeth  forward  with  its  movement.  Should  one  or  more  of  the  incisors  be  mal- 
tumed,  or  in  malalignment,  the  proper  attachments  for  producing  the  desired 
force  should  be  soldered  to  the  bands. 

The  expanding  force  of  the  nut  at  the  mesial  end  of  the  premolar  tube,  forces 
the  incisor  teeth  forward  and  to  the  left,  with  the  teeth  attached  to  the  bow.  The 
lateral  movement  of  the  incisors  can  be  aided  or  prevented  by  a  pull  or  push  move- 
ment of  the  bow  at  its  left  anchorage.  The  reaction  of  the  protruding  force  will 
tend  to  retrude  the  right  buccal  teeth  to  normal  occlusion  by  virtue  of  the  free 
inclination  action  of  its  peculiar  attachments.  (See  Movable  Anchorages,  Chapter 
XV.)     If  it  does  not  fully  accomplish  this,  the  intermaxillary  force  will  be  indicated. 

When  the  cuspid  space  is  more  completely  closed,  and  the  arch  proportionately 
contracted,  a  greater  degree  of  expanding  force  for  the  general  enlargement  and 
symmetrical  expansion  of  the  arch  will  be  demanded. 


Fig.  1.3.5. 


H.CeKt 


JU.Cenf. 


;?.i-at. 


L.h't. 


In  the  apparatus  shown  in  Fig.  135,  the  arch-bow.  No.  19,  or  20,  with  fixed 
lug  or  nut  to  engage  with  the  right  lateral,  is  principally  for  the  purpose  of  align- 
ment, to  keep  the  arch  in  symmetrical  form,  and  aid  in  the  correction  of  minor 
malalignments,  etc.  It,  however,  aids  in  the  distal  movement  of  the  right  buccal 
teeth  by  acting  directly  upon  the  molar.  The  lingual  appliance  is  unique  in  its 
adaptability  for  retruding  the  buccal  teeth,  and  is  one  of  the  most  common  methods 
employed  in  the  author's  practice. 


208 


I'ARl^    17.     DEXrO-FMIM.   MALOCCLUSIONS 


The  possibilily  of  applying  the  reaction  force  up(jn  the  molar  and  at  any 
nioment  transferring  it  to  the  premolar,  with  attachments  that  permit  free  inclina- 
tion movement,  is  of  the  greatest  advantage. 

The  mesial  end  of  the  right  lingual  push  bar,  No.  16,  or  18,  is  received  into 
a  flattened  tube  attachment  on  the  right  band  24,  which  carries  an  extension  to 
engage  with  the  central  to  distribute  the  protruding  force.  The  left  lingual  dis- 
tributing bar,  No.  18,  rests  in  a  seamless  tube  attachment  on  the  left  central  band 
14.  Tliis  is  done  to  preserve  the  rigidity  of  the  bar  which  would  be  softened  if 
soldered  to  the  band.  Should  it  be  found  desirable  that  this  bar  exerts  a  push  or 
pull  force  upon  any  tooth  or  teeth  to  which  it  may  be  attached,  it  can  be  threaded 
at  the  distal  ends  for  nuts  working  against  the  lingual  tube  on  molar  band  81. 
The  lingual  open-tube  attachment  on  left  cuspid  band  31,  is  to  prevent  the  bar 
from  sliding  on  its  inclined  lingual  face. 

The  bar-rest  jack,  No.  16,  can  be  located  at  any  point  best  adapted  to  exert 
the  proper  lateral  force.  As  its  general  location  will  be  near  to  the  incisal  alveolar 
ridge,  a  straight  jack  will  usually  not  interfere  with  the  functions  of  the  tongue, 
after  the  first  few  days.  Should  it  be  found  to  do  so,  the  drop  jack  shown  in  Chapter 
XLIX,  or  the  arc  jack,  will  be  indicated. 

An  effective  variation  in  the  above  apparatus  is 

shown  in  Fig.   136,  which  is  partictdarly  applicable 

when  nearly  all  of  the  expanding  movement  from  the 

jack  should  be  brought  to  bear  upon  the  right  pre- 

[ij'if^^^^     yy^ j,'^'^'^^^^S\      iiiolar  area  by  distributing  the  reacting  force  of  the 

jack  to  a  larger  number  of  teeth  through  the  medium 
of  the  lingual  distributing  bow.     This  bow.  No.   18 
extra  hard,  is  attached  to  the  right  lateral  by  soft- 
soldering  it  into  the  tube  attachment. 

It  will  be  seen  that  the  force  of  the  jack  upon  the  bow  will  aid  the  direction 
of  the  required  movement  by  its  tendency  to  carry  the  incisors  forward  and  over 
to  the  left.  As  the  premolars  are  forced  to  the  right,  in  connection  with  this 
movement,  the  straight  lingual  push  bar  should  be  bent  with  the  bending  pliers, 
in  proportion  to  the  demands  of  their  changing  relations  to  the  lateral,  and  to  per- 
mit the  latter  to  move  to  the  left  if  required.  If  it  is  desired  to  place  the  jack 
upon  the  distributing  bow  at  a  point  to  exert  a  more  direct  force  upon  the  incisors, 
a  locating  lug  or  nut  should  be  attached  to  prevent  the  jack  from  slipping. 


Fig.  13(i. 


CHAPTER  XXIV 

Type  B,  Division  1.  Class  I 

BILATERAL  MALERUPTION   OF   CUSPIDS   CORRECTED   WITHOUT 

EXTRACTION 

Bilateral  maleruption  of  the  cuspids  is  subject  to  the  same  rules  in  diagnosis 
and  prognosis  as  those  which  govern  the  Unilateral  characters.  The  correction 
of  these  cases  usually  requires  less  skill,  because  the  applied  forces  being  reciprocally 
bilateral,  balance  each  other  and  thus  aid  in  preserving  the  symmetry  of  the  arch. 

Fig.  137. 


When  the  dental  arch  is  not  contracted  laterally,  and  the  cuspid  spaces  are 
only  partially  closed,  the  apparatus  shown  in  Fig.  L37  will  usually  be  found  siiffi- 
ciently  effective  for  the  entire  correction.  An  arch  push  bow,  No.  18,  or  19,  attached 
to  the  incisors,  as  shown,  reacts  upon  the  buccal  teeth  through  the  medium  of  the 
same  character  of  reciprocating  anchorage  attachments  that  were  described  in  the 
apparatus  shown  in  Fig.  133,  which  is  constructed  with  a  view  of  inducing  a  distal 
movement  of  the  buccal  teetli  upon  one  side. 

209 


210  PART   17.     DENTO-FACIAL  MALOCCLUSIONS 

111  the  diagnosis  of  all  characters  of  irregularities,  and  especially  those  of  this 
class,  the  occlusion  of  the  teeth  in  relation  to  the  facial  outlines  is  of  the  greatest 
importance. 

In  a  large  proportion  of  cases  of  this  character,  the  buccal  teeth  have  moved 
slightly  forward  of  their  normal  occlusion,  which  may  be  corrected  by  the  reaction 
of  the  bow  alone,  but  it  will  be  seen  that  this  force  is  only  that  which  reacts  from 
moving  the  four  incisors  forward,  and  when  distributed  to  all  of  the  bitccal  teeth 
of  both  sides,  one  cannot  expect  more  than  a  slight  proportional  distal  movement 
of  these  teeth  from  that  source.  Therefore,  the  intermaxillary  force,  which  may 
properly  be  termed  the  great  adjuster  of  occlusion,  will  be  indicated  in  a  large 
proportion  of  cases.  This  is  readily  attached  to  the  upper  by  clasping  to  the  arch- 
bow  the  intermaxillary  hook-tubes  from  which  the  elastics  extend  to  the  disto- 
buccal  aspect  of  the  lower  anchorages. 

At  this  juncture  there  should  arise  the  important  question  as  to  the  degree 
of  movement — if  any — which  the  lower  teeth  should  undergo  for  the  greatest 
perfection  to  the  facial  outlines,  so  that  in  the  construction  of  the  appliances,  the 
forces  of  reaction  may  be  nullified,  or  on  the  other  hand,  utilized  to  the  fullest 
extent.  This  special  feature  of  the  work  is  fully  described  in  Chapter  XVI,  Inter- 
maxillary and  Occipital  Force. 

Fig.  138. 


Not  uncommonly  the  spaces  between  the  laterals  and  premolars  are  nearly  or 
quite  closed,  and  the  eruption  of  the  cuspids  has  advanced  so  far  they  prevent 
placing  a  heavy  arch-bow  on  the  outside  of  the  dental  arch.  This  is  well  shown  in 
Fig.  138.  When  this  occurs,  the  apparatus  shown  in  Fig.  139  will  be  indicated. 
The  lingual  yoke  push  bow  here  shown  with  premolar  movable  anchorage  attach- 
ments, is  one  of  the  most  practical  and  effective  combinations  in  the  author's 
practice.  It  is  similar  in  its  action  to  that  shown  in  Fig.  137,  but  is  far  more  appli- 
cable for  extensive  movements. 


CHAPTER  XXIV.     TYPE  B.     DIVISIOX   1.     CLASS  I. 


211 


The  lingual  yoke  bow  is  designed  to  exert  an  evenly  distributed  pressure  upon 
the  front  teeth  and  prevent  the  lateral  incisors  from  sliding  along  the  bow.  The 
yoke  and  bow  are  attached  together  by  fitting  the  two  into  an  elliptical  tube 
which  has  been  made  by  slightly  flattening  a  round  seamless  thin  tube,  by  passing 
it  through  the  rollers.  When  in  place,  the  V-spaces  are  closed  by  pinching  the 
central  portion  of  the  tube  with  blunt  cutting  pliers.  The  joint  is  then  firmly 
attached  with  soft-solder. 

Fig.  139. 


In  connection  with  this,  the  author  usually  employs  at  the  beginning  of  the 
operation  a  light  alignment  bow.  No.  22  or  23,  principally  for  its  resilient  action  as 
shown  in  the  buccal  views  of  the  apparatus. 

There  is  no  use  in  attempting  to  force  a  cuspid  or  other  teeth  into  alignment 
until  there  is  sufficient  room  for  them  to  move  in.  In  nearly  all  instances  where 
the  cuspids  are  in  the  position  shown,  they  will  usually  move  into  place  without 
artificial  aid  as  rapidly  as  space  is  made  for  their  eruption  into  normal  position. 

In  assembling  the  apparatus,  the  yoke  of  the  lingual  bow  is  bent  to  rest  properly 
against  the  front  teeth,  engaging  with  hook  attachments  on  the  incisor  bands. 
If  the  arch  is  of  normal  width,  the  distal  ends  of  the  bow  should  lie  evenly  in  the 
anchorage  tubes  without  pressure;  but  if  the  molar  area  of  the  arch  is  laterally 
contracted  or  expanded,  the  bow  should  be  bent  to  exert  a  corrective  force.  The 
molar  bands  may  be  placed  first,  then  one  of  the  premolar  bands  with  the  bow  in 


212 


PART   VI.    DENTO-FACIAL  MALOCCLUSIONS 


Fk;.  140. 


its  tuV)e.  In  placing  the  other  premolar  band,  lift  the  free  end  of  the  bow  and  slip 
the  tube  over  the  end,  and  then  with  a  hinge  movement  carry  the  band  on  to  the 
tooth.  Another  way  is  to  place  the  premolar  bands  with  the  bow  in  the  tube  attach- 
ments together.  This  may  be  done  before  or  after  placing  the  molar  bands,  as  the 
premolar  tubes  can  be  easily  sprung  into  the  molar  tube  attachments.  The  incisor 
bands  should  be  placed  last,  the  lingual  hooks  having  been  bent  properly  in  the 
preliminary  assembling  so  as  to  go  easily  to  place  and  subseqviently  clasp  the 
bow.  The  alignment  arch-bow  may  be  placed  later,  unless  demanded  for  the 
correction  of  the  incisors;  and  even  then  it  may  be  impossible  to  place  it  at  first 
on  account  of  the  position  of  the  cuspids. 

A  very  practical  variation  of  this  apparatus  is 
shown  in  Fig.  140,  which  will  be  found  effective 
in  many  cases  where  the  malalignment  of  the 
incisors  will  not  permit  an  even  application  of  the 
yoke,  and  especially  where  there  is  ciuite  a  difference 
demanded  in  the  amount  of  force  on  each  side. 

The  lingual  bars.  No.  18,  engage  directly 
with  the  laterals  through  the  medium  of  elliptical 
tube  attachments.  Fig.  135,  which  support  an 
extension  plate  to  engage  with  the  central.  The 
bars  pass  through  movable  attachment  tubes  on 
the  premolars,  and  into  the  molar  tubes.  They  are  threaded  for  mesial  nuts, 
as  shown.  By  this  combination  it  will  be  seen  that  the  force  of  reaction  may  be 
first  directed  upon  the  molars,  and  at  any  time  transferred  to  the  premolars 
with  the  assurance  of  the  greatest  possible  utility  of  the  force  toward  a  distal  move- 
ment of  the  buccal  teeth.  It  is  needless  to  say  that  the  arch-bow,  that  is  the  most 
applicable  as  regards  size,  etc.,  will  always  be  found  of  great  assistance.  In  assem- 
bling this  apparatus,  the  lateral  and  premolar  bands,  with  the  push  bar,  should  be 
placed  together.  In  placing  the  molar  band,  slip  the  lingual  tube  over  the  distal 
end  of  the  bar  and  then  with  a  hinge  movement,  carry  the  band  to  place.  Finally, 
place  the  central  incisor  bands. 

In  the  case  illustrated  by  Fig.  13S,  is  shown  the  common  occlusion  of  the  buccal 
teeth  in  this  type.  This  will  usually  demand  the  application  of  the  disto-mesial 
intermaxillary  force  at  the  first  moment  that  it  can  be  properly  applied.  This, 
added  to  the  reactive  force  of  the  lingual  bow,  will  force  the  buccal  teeth  distally 
to  their  originally  intended  normal  occlusion.  When  considerable  distal  movement 
of  the  buccal  teeth  is  demanded,  the  force  may  be  applied  first  to  the  most  distal 
molars  through  the  medium  of  sliding-tubes  or  span-hooks,  then  the  force  can  be 
transferred  to  the  next  tooth  in  front,  etc.  This  is  fully  described  in  connection 
with  the  appliance  shown  by  "5,"  Fig.  141. 

In  those  cases  when  the  incisors  demand  a  bodily  labial  movement,  the  front 
teeth  are  first  placed  in  alignment  so  that  the  incisors  are  in  position  to  be  grasped 


CHAPTER   XXIV.     TYPE  B.     DIVISION   1.     CLASS  I. 

Fig.  141. 


213 


214  PART   VI.    DENTO-FACIAL  MALOCCLUSIONS 

by  the  power  bow.  This  is  fully  described  and  illustrated  in  Chapter  XX.  The 
whole  operation  in  the  most  difficult  of  cases  of  Malcrui^tion  of  tlie  Cuspids,  is 
usually  finished  within  one  year. 

In  a  very  large  majority  of  youthful  cases,  a  moderate  maleruption  of  cuspids 
can  be  very  readily  corrected  with  the  Midget  Apparatus  described  in  Chapter  XX. 

Intermaxillary  and  Occipital  Force. — There  is  no  Class  in  which  the  inter- 
maxillary and  occipital  forces  are  more  applicable  than  in  malocclusions  which  are 
mainly  characterized  by  a  maleruption  of  the  upper  cuspids,  particularly  in  those 
cases  which  demand  a  considerable  distal  movement  of  the  tipper  buccal  teeth. 

In  Fig.  141,  "1"  shows  a  common  malocclusion  of  this  division.  If  the  lower 
teeth  are  in  normal  dento-facial  pose,  it  indicates  that  a  premature  loss  of  the 
deciduous  teeth  has  been  followed  by  a  drifting  forward  of  the  tipper  buccal  teeth, 
demanding  that  they  be  restored  to  normal  occlusion  by  a  distal  movement,  with 
no  mesial  movement  of  the  lowers.  This  will  make  room  for  the  eruption  of  the 
upper  cuspids. 

There  are  only  two  ways  in  which  this  can  be  accomplished  without  materially 
changing  the  position  of  the  other  teeth.  First,  is  by  the  employment  of  occipital 
force  with  bow  C,  "2"  and  "4."  The  inner  bow  "c"  attached  to  the  main  occipital 
bow  "C"  directs  the  entire  force  by  means  of  its  sliding  attachment  upon  the  first 
premolars,  and  through  them  it  is  distributed  to  the  rest  of  the  buccal  teeth.  The 
rotating  tendency  of  this  distally  directed  force  upon  the  buccal  surfaces  of  the 
premolars  is  counteracted  by  elastic  or  wire  ligatures  attached  to  the  lingual  hooks. 

The  second  and  perhaps  more  practical  method  for  yovmg  patients  is  through 
the  medium  of  the  intermaxillary  force  with  the  lower  denture  firmly  anchored  to 
prevent  its  mesial  movement,  as  shown  in  "3."  The  intermaxillary  hooks  soldered 
to  open  tubes  "a"  clasped  to  the  arch-bow,  engage  with  the  premolar  attachments 
and  communicate  the  distally  directed  force  as  explained.  The  mesial  nuts  at  the 
molars  are  for  the  purpose  of  keeping  up  a  proper  tension  on  the  incisors,  or  for 
their  labial  movement,  if  demanded.  Both  intermaxillary  and  occipital  forces  may 
be  employed  at  the  same  time,  as  shown  in  "2;"  "5"  illustrates  a  method  of  apply- 
ing the  intermaxillary  force  directly  upon  the  molars  through  the  medium  of  open 
sliding  tubes.  A  more  practical  method,  however,  is  by  means  of  the  span  inter- 
maxillary hooks,  shown  and  described  under  Figs.  74  and  75,  Chapter  XVI. 


CHAPTER  XXV 

Type  C,  Division  1,  Class  I 

BILATERAL  AL4LERUPTI0N   OF  UPPER   CUSPIDS,  REQUIRING   EXTRACTION 

As  has  been  repeatedly  stated,  the  malocclusion  which  is  characterized  by 
a  maleruption  of  the  upper  cuspids  arises  in  all  three  Classes;  and  while  it  is 
found  far  more  frequently  in  Class  I — where  its  correction  should  be  performed 
without  extraction — it  is  not  uncommon  to  find  this  same  character  of  maleruption 
of  the  cuspids  in  every  type  of  inherited  disto-mesial  malrelations  of  the  buccal 
teeth  of  Classes  II  and  III. 

Differential  Diagnosis  and  Treatment 

Though  the  present  Type  C  under  consideration  is  distinctly  a  Class  II  Type, 
it  has  been  deemed  advisable  for  teaching  purposes  to  place  its  practical  treat- 
ment in  connection  with  Maleruption  of  the  Cuspids  of  Class  I,  where  close  com- 
parisons in  diagnosis  and  treatment  can  be  drawn. 

Specifically,  it  is  a  locally  caused  irregularity  which  has  arisen  and  has  been 
ingrafted  upon  an  inherited  Class  II  malocclusion  of  the  buccal  teeth,  in  the  same 
way  that  this  same  character  of  irregularity  of  the  cuspids  is  ingrafted  upon  in- 
herited normal  occlusions  of  Class  I. 

As  fully  explained  in  the  previous  chapter  relative  to  Type  B,  a  full  mesial 
malocclusion  of  the  upper  buccal  teeth  may  also  arise  purely  from  a  local  cause, 
with  the  production  of  the  characteristic  Maleruption  of  Ctispids  through  the 
premature  loss  of  deciduous  teeth,  permitting  the  upper  buccal  teeth  to  drift 
forward  until  they  jump  the  cusps,  and  thus  entrap  the  cuspids  and  force  them  to 
erupt  through  the  gums  above.  If  one  is  sure  that  the  condition  has  arisen  in  this 
way,  and  the  case  is  presented  before  the  eruption  of  the  second  molars,  it  would 
be  proper  to  force  the  upper  buccal  teeth  back  to  the  normal  occlusion  which  nature 
intended;  and  especially  is  this  true  if  the  lower  denture  is  more  or  less  retruded 
in  relation  to  the  mandible,  as  in  Types  of  Division  1,  Class  11. 

On  the  other  hand,  if  there  is  every  reason  to  believe  from  the  occlusion  of 
the  buccal  teeth  and  their  relations  to  the  facial  outlines  that  the  cuspid  malerup- 
tion has  arisen  in  connection  with  a  true  Class  II  malocclusion,  the  next  thing  to 
determine  is  the  Division  and  Type  of  that  Class  in  which  it  has  occurred,  and  then 
treat  the  case  according  to  its  demands.  All  of  this  is  fully  outlined  in  the  diag- 
nosis and  treatment  of  Class  II,  where  it  will  be  found. 

Notwithstanding  the  fact  that  the  malrelations  of  the  dentures  are  the  same, 
there  is  a  very  decided  difference  in  the  facial  outlines  which  they  produce,  and 

215 


216  PART    VI.     DEXTO-I'ACIAL   MALOCCLUSIONS 

consequently  a  very  decided  difference  in  tlic  character  of  treatment  they  demand. 
For  instance,  if  the  maleruption  of  the  cuspids  has  occurred  in  a  case  of  Class  II, 
in  which  the  distal  malrelation  of  the  lower  denture  is  due  to  its  retruded  position 
in  relation  to  the  mandible,  causing  a  pronounced  retrusion  of  the  lower  lip  in  rela- 
tion to  a  normally  posed  chin,  the  extraction  of  premolars  to  correct  the  cuspid 
malposition  would  be  decided  malpractice.  But  on  the  other  hand,  if  the  lower 
lip  and  chin  are  normally  posed,  it  indicates  that  the  case  is  an  inherited  upper 
protrusion  demanding  the  extraction  of  premolars  to  align  the  cuspids. 

Fig.  142. 


In  Fig.  142  is  .shown  a  case  which  would  have  been  a  pronounced  upper  protru- 
sion with  lower  normal  had  it  not  been  that  the  maleruption  of  the  cuspids  per- 
mitted a  retrusive  movement  of  the  incisors  through  the  action  of  the  upper  lip. 
This  patient  being  twenty  years  of  age  had  established  a  perfect  interdigitating 
occlusion  of  the  buccal  teeth,  as  shown  on  the  left.  The  result  of  treatment  by 
extracting  the  first  premolars  is  shown  on  the  right. 

Originally,  the  lips  of  this  patient  were  somewhat  protrusive,  which  would 
have  been  decidedly  enhanced  had  there  been  an  attempt  to  shift  the  dentures  to  a 
normal  occlusion  without  extraction. 

Hundreds  of  cases  of  this  particular  character  were  perfectly  corrected  by 
dentists  in  the  past  with  no  other  treatment  than  the  extraction  of  the  first  pre- 
molars, and  as  mentioned  before,  this  was  one  of  the  reasons  which  led  to  the  fre- 
quent malpractice  of  extraction  in  all  maleruptions  of  upper  cuspids. 

Fig.  130,  Chapter  XXII,  will  serve  to  illustrate  the  facial  and  dental  character 
and  results  of  treatment  in  a  case  of  this  Division  of  malocclusion.  It  will  be  seen 
by  the  facial  cast  on  the  left  that  the  lower  lip  and  chin  are  in  normal  dento-facial 
pose;  and  consequently  with  the  tipper  buccal  teeth  in  mesial  malocclusion,  this 
case — ^had  it  not  been  for  the  maleruption  of  the  cuspids — would  have  resulted  in 


CHAPTER  XXV.     TYPE  C.     DIVISION   1.     CLASS  I.  217 

a  pronounced  upper  protrusion,  demanding  the  extraction  of  the  first  premolars; 
consequently,  that  points  the  way  to  the  proper  treatment  of  this  type.  When 
the  cuspids  are  moved  to  the  places  of  the  extracted  premolars,  the  overlying  prom- 
inences of  the  lips  are  reduced  with  a  complete  correction  of  the  facial  outlines. 

In  the  treatment  of  these  cases,  this  type  is  the  easiest  to  correct  and  retain 
of  all  the  maleruptions  of  the  cuspids.  In  the  case  of  the  young  man  shown  in 
Fig.  142,  correction  was  accomplished  in  a  little  over  six  months.  Afterwards,  he 
wore  the  retainers  only  about  the  same  length  of  time,  and  now  after  four  years, 
his  teeth  have  never  changed  their  positions,  except  to  more  perfectly  correct 
their  occlusion. 

In  this  case,  as  in  others  of  its  kind,  three-band  stationary  anchorages  were 
employed  on  the  upper  to  prevent  the  slightest  mesial  movement  of  the  buccal 
teeth.  To  these  were  soldered  two  buccal  tubes.  The  upper  tubes  carried  traction 
bars  No.  19  to  the  cuspids,  and  the  lower  tubes  carried  a  No.  22  alignment  arch- 
bow  to  the  incisors.  If  the  arch  requires  lateral  expansion,  the  arch-bow  may  be 
No.  18  extra  spring,  though  if  considerable  expansion  is  demanded,  a  lingual 
spring  or  jack  expander  is  preferable. 


CHAPTER   XXVI 

Type  D,  Division  1,  Class  I 

THUMB-SUCKING   PROTRUSION  OF  THE  UPPER  FRONT  TEETH 

^"^''-  ^^^- The  childhood  habit  of  thumb-sucking  when  occurring 

with  patients  whose  dentures  would  otherwise  have 
assumed  a  normal  occlusion,  frecjuently  produces  a 
dento-facial  appearance  that  is  quite  similar  to  upper 
protrusions  found  in  Class  II.  Therefore,  in  cases  of 
dento-facial  upper  protrusion,  if  the  buccal  teeth  are 
found  in  normal  occlusion,  and  the  chin  and  lower  lip 
are  in  esthetic  pose,  and  in  harmonious  relation  to  the 
facial  outlines,  outside  of  the  dento-facial  area,  the  mal- 
position has  undoubtedly  been  caused  by  thumb-sucking. 
Commonly,  the  upper  arch  is  narrowed  by  the  contract- 
ing action  of  the  buccinator  muscles,  and  the  upper 
front  alveolar  ridge  and  front  teeth  are  pulled  forward 
by  the  ball  of  the  thumb  resting  in  the  roof  of  the 
mouth,  usually  causing  a  decided  labial  inclination 
and  wide  interproximate  spaces.  The  lower  incisors, 
moreover,  will  often  be  found  retruded,  enhancing  the 
protruding  effect  of  the  upper. 
(3ne  has  but  to  place  the  thumb  in  the  roof  of  the  mouth  and  suck  on  it  to 
fully  understand  the  mechanical  action  of  the  several  forces,  i.  e.,  the  pressure  of 
the  buccinator  muscles,  the  forward  pull  of  the  ball  of  the  thtimb  upon  the  upper, 
and  the  pressure  of  the  knuckle  upon  the  lower  incisors,  with  the  muscles  of  the 
arm  relaxed  and  its  weight  pulling  downward. 

^     , , ,  A  very  little  thought  will  determine  also  the  effect  of  this 

Fig.  !44.  -'  ° 

cause  upon  Classes  II  and  III  Malocclusions. 

The  habit  which  commences  in  infai:icy,  and  frequently 
continues  into  the  early  periods  of  secondary  dentition,  may 
be  readily  stopped  with  the  appliance  shown  in  Fig.  144, 
which  consists  of  a  loosely  telescoping  bar  and  tube,  straight 
or  curved,  one  end  of  each  being  soldered  to  deciduous  molar 
bands,  as  shown.  The  easy  gliding  movement  of  the  bar 
permits  the  natural  growth  expansion  of  the  arch.  This 
appliance  produces  no  material  disturbance,  except  that  it  prevents  the  thumb 
from  taking  its  accustomed  position,  and  at  once  stops  the  habit. 

218 


CHAPTER  XXVJ.     TYPE  D.     DIVISIOX   1.     CLASS  I.  219 

The  most  pronounced  protrusion  arising  from  this  cause  in  Class  I,  is  usually 
not  difficult  to  correct  with  a  light  traction  arch-bow  from  stationary  anchorages 
on  the  upper.  If  the  lower  front  teeth  are  in  a  retruded  malposition,  an  expansion 
arch-bow  No.  20,  or  19,  from  lower  stationary  anchorages  to  attachments  on  the 
incisors,  will  usually  be  sufficient  to  align  these  teeth.  The  main  action  of  this 
bow  should  be  through  its  resiliency  from  the  cuspids.  The  demands  for  varia- 
tions to  correct  other  complications  will  be  apparent  from  an  acquaintance  with 
other  cases. 

The  object  of  the  stationary  anchorages  on  the  upper  and  lower  buccal  teeth 
is  to  prevent  disturbing  their  normal  disto-mesial  occlusion  and  dento-facial 
relations.  Any  disto-mesial  malrelations  of  occlusion  are  easily  corrected  with  the 
intermaxillarv  force. 


CHAPTER   XXVII 

Type  F,  Division  1,  Class  I 

LATERAL   MALOCCLUSION 

There  are  two  very  distinct  forms  of  lateral  malocclusion  of  the  dentures, 
both  of  which  arise  from  local  causes.  One  is  due  to  an  acquired  malposition  of 
the  buccal  teeth  which  forces  the  mandible  far  to  one  side  during  a  masticating 
closure  of  the  dentures,  while  the  other  form  is  due  to  a  unilateral  malformation 
of  the  mandible  itself,  through  causes  that  will  be  fully  explained. 

First  Form 

The  first  form  of  lateral  malocclusion  is  apparent  only  during  the  mastication 
of  food.  At  other  times  when  the  muscles  are  at  rest  with  the  jaws  slightly  apart, 
and  if  the  patient  is  laughing  or  talking,  the  condyles  are  evenly  posed  in  their 
sockets  with  the  chin  in  the  median  line,  but  immediately  upon  any  attempt  to 
masticate,  the  features  are  more  or  less  disfigured  l)y  this  necessary  movement  of 
the  mandible. 

This  condition  which  probably  arises  during  secondary  dentition,  becomes 
permanently  fixed  by  the  eruption  and  malocclusion  of  other  oncoming  teeth 
seeking  the  fulfillment  of  their  masticating  functions. 

In  the  pronounced  form  of  this  malocclusion,  the  decided  lateral  movement 
of  the  jaws  in  the  effort  to  masticate  food  is  at  times  so  noticeably  awkward 
and  deforming  to  the  facial  outlines,  reminding  one  of  a  cow  chewing  her  cud, 
it  becomes  exceedingly  annoying  and  embarrassing  to  the  patients  and  their 
friends. 

Fig.  145  was  made  from  the  occlusal-bite  models  of  three  cases  in  practice. 
Those  on  the  left  represent  the  dentures  in  occlusion  at  the  beginning  of  the  opera- 
tion. Note  the  pronounced  lateral  malrelation  of  the  tipper  dentures  to  the  lower 
front  teeth.  On  the  right  are  shown  tlie  corrected  cases.  The  one  at  the  top  is 
from  the  models  of  a  miss  sixteen  years  of  age,  of  high  social  standing,  and  beautiful 
when  her  features  were  in  repose  or  when  she  was  talking  or  laughing.  That  in 
the  center  is  from  the  models  of  a  miss  twenty-seven  years  of  age,  a  ceramic  artist 
by  profession,  whose  facial  deficiencies  were  decidedly  emphasized  by  the  same 
deforming  action  of  the  jaws  in  eating  that  characterizes  this  malocclusion.  The 
one  below  is  from  a  child  about  seven  years  of  age. 

In  the  correction  of  this  character  of  malocclusion,  it  is  necessary  to  break 
up  the  entire  occlusal  relation  of  the  dentures  and  place  them  in  normal  bucco- 
lingual  dento-facial  relations.     This  is  not  an  easy  operation  with  ordinary  ap- 

220 


CHAPTER  XXVII.    TYPE  F.    DIVISION  1.    CLASS  I.  221 

pliances,  because  of  the  deep  and  strongly  fixed  occluding  lateral  planes — some  of 
the  premolars  often  shearing  by  each  other  without  touching  their  occluding 
surfaces. 

The  work  in  the  more  pronounced  cases  may  be  gi'eatly  facilitated  by  placing 
hollow  crowns  over  the  first  lower  molars  with  heavily  built  inclined  planes  to  open 
the  bite  and  force  the  dentures  to  a  normal  linguo-buccal  position  while  eating. 

Fig.  145. 


The  teeth  are  then  more  easily  shifted  to  their  new  positions  and  occlusal  relations. 

Other  than   this,  the  various  means  which  may  be  successfully  employed  are 

applicable  variations  of  the  usual  methods,  which  need  not  be  described  in  detail 

as  no  two  cases  are  alike.    For  children  who  have  not  shed  the  temporary  buccal 

teeth — as  shown  at  the  bottom  of  Fig.  145 — strong  guiding  plates  attached  to 

stationary  anchorages  are  usually  sufficient  for  the  entire  correction  of  the  buccal 

occkision. 

Second  Form 

The  second  form  of  lateral  malocclusion  is  due  to  a  unilateral  malformation  of 
the  mandible,  and  arises  during  the  very  early  developmental  processes  of  the  bones, 
resulting  in  the  production  of  a  more  obtuse  or  straightened  angle  of  the  ramus 
and  its  condyle  upon  one  side  only,  in  its  relation  to  the  body  of  the  mandible. 


222  PART    VI.     DRXrO-FACTAL    MAWCCfTSIONS 

While  this  condition  is  not  so  very  rare  in  its  minor  degrees,  its  occasional  pro- 
nounced state  forms  one  of  the  most  unpleasant  dento-facial  deformities  and  one 
of  the  most  difficult  to  correct,  because  of  the  profound  complications  it  produces. 
Moreover,  it  is  so  distinctive  in  its  dento-facially  deforming  character  and  demands 
of  treatment,  it  is  important  that  every  orthodontist  should  give  to  it  a  careful 
consideration  and  study. 

The  temporo-maxillary  articulation  in  the  normal  state,  is  the  only  one  in  the 
body  which  permits  a  considerable  normal  movement  in  relation  to  its  functional 
seating  in  the  sockets.  When  the  mandible  is  forced  directly  forward  in  normal 
movements,  both  condyles  glide  evenly  forward  upon  their  inter-articular  fibro 
cartilages,  iintil  they  rest  against  the  posterior  inclined  planes  of  the  articular 
eminences,  where  they  are  prevented  from  passing  over  the  crests  by  the  strong 
tension  of  the  capsular  and  other  ligaments.  When  the  normal  movement  is  only 
in  a  lateral  or  sidewise  direction,  one  condyle  alone  moves  forward,  while  the  other 
remains  in  its  socket. 

In  this  second  form  of  lateral  malocclusion,  both  condyles  remain  in  their 
most  posterior  positions  in  the  glenoid  cavities,  while  the  front  of  the  mandible — 
shown  by  the  chin  and  the  lower  front  teeth — is  far  to  one  side  of  its  normal  medio- 

Fir..  Ur.. 


occlusal  relations,  showing  that  the  body  of  the  mandible  is  bent  to  one  side. 
Fig.  146  shows  a  few  characteristic  positions  of  the  front  teeth  made  from  occlusal 
impressions  of  three  cases  in  practice  having  this  peculiar  malocclusion.  The 
condition  may  be  caused  by  intra-uterine  or  accouchement  forces,  or  more  probably 
from  the  thoughtless  habit  of  some  mothers  in  causing  the  young  babe  to  nurse 
and  lie  far  more  often  upon  one  side  than  the  other.  From  the  latter  cause,  the 
mandible  is  forced  to  remain  in  a  strained  lateral  malposition  for  repeated  periods 
of  time  during  the  very  early  years  of  its  yielding  immaturity  when  very  slight 
continued  pressure  will  result — if  not  corrected — in  a  permanent  malformation 
of  the  bones. 

It  seems  probable  that  this  is  the  main  if  not  the  only  cause,  in  that  it  so  exactly 
corresponds  to  the  condition  which  would  inevitably  arise  under  these  circum- 
stances through  the  forces  of  the  ligaments  and  muscles  exerted  in  that  manner 


CHAPTER   XXVII.     TYPE  F.     DIVISION   1.    CLASS  I.  223 

and  at  that  age.  The  modus  opcnnidi  of  this  action  may  be  explained  as  follows: 
The  condyle  upon  one  side  is  forced  firmly  back  against  the  posterior  articular 
wall  of  the  glenoid  cavit3^  and  the  other  condyle  with  the  ramus  being  held  forward 
by  the  forced  position  of  the  body  of  the  mandible  is  vinder  the  strain  of  the  liga- 
ments and  muscles,  which  tend  to  force  it  back  into  its  socket;  with  the  result 
that  this  slight  continued  force,  during  early  growth  development,  prevents  the 
ramus  and  condyle  upon  that  side  from  assuming  the  normal  form  which  is  more 
nearly  that  of  a  right  angle  in  relation  to  the  body.  This  action  is  somewhat  similar 
in  its  results  to  that  which  straightens  the  angles  of  both  rami  in  the  regular  open- 
bite  malocclusion  from  mouth-breathing. 

By  increasing  the  obtuseness  of  the  angle  of  the  ramus  upon  one  side  without 
debarring  its  growth  development  in  other  particulars,  the  distance  from  the 
symphysis  of  the  chin  to  the  condyle  is  necessarily  increased  upon  that  side, 
and  the  body  of  the  mandible  and  its  contained  teeth  is  forced  abnormally  forward, 
while  on  the  opposite  side  the  disto-mesial  relations  of  occlusion  may  be  unchanged ; 
though  the  lateral  malposition  of  the  jaw,  however,  forces  the  lower  front  teeth, 
the  premolars,  and  sometimes  the  first  molar  upon  this  side,  into  bucco-labial 
malocclusion.  This  forward  movement  of  the  buccal  teeth  upon  the  one  side  fre- 
quently amounts  to  a  full  mesial  malinterdigitation  of  the  cusps ;  and  in  one  case, 
fully  described  under  Division  4,  Class  III,  and  illustrated  with  Fig.  230,  which 
arose  in  connection  with  a  retruded  upper,  the  mesial  line  of  the  left  lower  first 
molar  was  even  with  the  point  of  the  upper  cuspid.  In  connection  with  this 
condition  also,  the  almost  invariable  restilt  is  an  open-bite  malocclusion,  for  the 
reason  that  any  change  toward  straightening  the  normal  angles  of  the  rami  must 
to  that  extent  prevent  the  front  teeth  from  coming  together,  thus  permitting  only 
the  most  distal  molars  to  occlude,  while  all  teeth  mesial  to  this  are  evenly  opened 
toward  the  front,  resulting  in  the  production  of  all  the  characteristics  of  an  open- 
bite  and  general  malocclusion  of  the  entire  dentures,  while  the  protruded  lateral 
malposition  of  the  mandible  and  lower  teeth  usually  gives  to  these  cases  all  the 
peculiar  facial  characteristics  of  Class  III. 

If  this  lateral  malposition  of  the  lower  jaw  is  discovered  during  babyhood,  it 
doubtless  can  be  easily  corrected  with  a  moderate  degree  of  digital  manipulation. 
At  five  years  of  age,  and  possibly  at  ten,  some  ingenious  orthopedic  appliances 
could  be  constructed  that  would  probably  bend  the  mandible  back  to  the  normal 
shape,  and  thus  prevent  this  very  unhappy  dento-facial  deformity.  Later,  the 
usual  possible  method  of  correction  consists  in  shifting  the  crowns  of  both  dentures 
toward  the  normal  occlusal  relations — the  one  to  the  right  and  the  other  to 
the  left.  In  connection  with  this  lateral  movement,  the  open-bite  can  be  corrected 
by  an  extrusive  and  retrusive  movement  of  the  lower  front  teeth.  If  the  case  is 
complicated  with  an  abnormally  retruded  upper,  this  feature  should  be  corrected 
by  a  bodily  labial  movement  of  the  upper  front  teeth  in  the  usual  manner,  but  with 
forces  applied,  also  to  move  them  laterally  toward  their  normal  relations  with  the 


224 


PART    VI.     DEXTO-FACFAL   }rA  LOCCLrsrONS 


lower.  In  those  cases  where  the  lower  denture  and  chin  are  carried  far  to  one  side 
by  the  lateral  bendinj;  of  the  mandible,  there  is  very  little  hope,  after  twelve  years 
of  age,  of  accomplishing  anything  toward  a  restoring  movement  of  the  mandible, 
or  in  other  words,  a  permanent  movement  of  the  chin  toward  the  median  line. 
But  a,  sur]jrising  dental  and  facial  correction  will  always  ensue  l.iy  moving  the  front 
teeth  of  one  denture  to  the  right  and  the  other  to  tlic  left  toward  their  normal 

Fig.  147. 


occluding  x^elations,  thus  harmonizing  the  immediate  relations  of  the  dental  and 
facial  lines.     This  is  well  illustrated  in  the  following  case. 

If  the  lower  denture  is  protruded,  as  commonly  obtains  in  these  cases,  a  first 
lower  premolar  may  be  extracted  on  the  protruded  side,  and  the  forces  applied  so 
as  to  carry  all  the  front  teeth  and  opposite  premolars  over  to  that  side  mesio- 
distally  and  lingually,  to  close  the  space. 

Fig.  147  shows  this  character  of  lateral  malocclusion  with  the  usual  open-bite 
and  prognathic  mandible  and  lower  denture.  On  the  left  it  illustrates  the  facial 
and  dental  casts  of  a  miss,  seventeen  years  of  age  when  she  presented  for  treat- 


CHAPTER  XXVII.     TYPE  F.     niVISIOX   1.     CLASS   I. 


225 


Fk;.  14S. 


ment.    From  some  cause,  the  lower  jaw  was  bent  decidedly  to  the  right,  as  can  be 

seen  by  the  relatioiis  of  the  upper  and  lower  incisors;  while  all  the  teeth  assumed 

exactly  the  malrelations  described  in  the  foregoing  text.     In  this  case  the  mal- 

relation  of  the  dentures  was  enhanced  by  a  retruded  position  of  the  upper  front 

teeth.     This  was  apparently  due  to  the  early  extraction  of  the  upper  left  lateral, 

and  a  lingual  maleruption  of  the  upper  right  cuspid.     The  profile  plaster  casts  do 

not   show,   as  a  front   view  would   have   done, 

the  extent,  on  the  one  hand,  of  the  facial  deformity 

caused  l)y  the  protruded  lower  jaw  carried  far 

to  the  right  in  connection  with  a  retruded  upper 

and  open-bite  malocclusion,  and   on  the  other, 

the  final  improved  facial  effect.     The  latter  is 

more    perfectly    illustrated    in    Fig.    148,    which 

was   made   from   a   photograph    of   the   patient 

taken  several  years  after  the  case  w'as  finished. 

The  auxiliar>^  appliance  for  shifting  the  oc- 
clusal relations  of  the  lower  front  teeth  to  the 
left  in  this  case,  is  shown  in  Fig.  149.  It  shows 
the  plaster  casts  in  an  articulator  in  the  original 
occlusal  position  of  the  case,  with  a  duplicate  of 
the  lower  apparatus  which  the  patient  wore  to  correct  the  upcn-bitc  malocclusion, 
and  move  all  the  lower  front  teeth  to  the  left.  The  upper  apparatus  for  the 
bodily  labial  movement  of  the  incisors  is  not  shown.  .  After  the  lower  left  first 
premolar  was  extracted  in  this  case,  a  No.  22  arch-bow  was  made  to  pass 
through  open-tube  attachments  on  all  the  front  teeth  to  correct  and  hold  them  in 
alignment.     The  bow  was  fixedly  attached  to  the  right  loweir  cuspid  though  its 

Fig.  149. 


distal  end,  on  that  side,  passed  through  a  single  molar  anchorage  tube  for  align- 
ment security.  Its  motive  force  was  from  a  three-band  stationary  anchorage  on 
the  left  side.  The  directions  of  this  force  upon  the  lower  front  teeth  were  toward 
the  left,  lingually  and  extrusively.     In  addition  to  this,  and  the  regular  disto- 


226  I'MiT    17.     DENTO-FACIAL   MALOCCLLSlOyS 

mesial  clastic  on  the  left  side,  intermaxillary  elastics  were  attached  to  hooks  upon 
the  linj^ual  surface  of  the  right  lower  cuspid,  and  extended  to  attachments  on  the 
left  upper  cuspid.  This  force  which  tends  to  pull  the  lower  to  the  left  and  the  upper 
to  the  right  is  distributed  through  tlic  mediimi  of  the  arch-bows  to  the  entire  front 
portion  of  both  dentures.  This  may  be  fvirther  supplemented  with  short  elastics, 
as  shown,  from  hooks  on  the  lingual  surfaces  of  the  upper  right  premolars  and  mo- 
lars to  attachments  on  the  buccal  surfaces  of  the  teeth  below.  The  latter  resort 
is  the  common  method  in  the  author's  practice  for  the  lateral  shifting  of  buccal 
occlusion.  It  woiild  seem  as  if  this  apparent  complicated  arrangement  of  elastics 
would  be  a  very  difficult  one  for  the  frequent  necessary  readjustments  at  meal- 
times, but  patients — especially  the  young  ones — soon  learn  to  remove  and  readjust 
the  elastics  far  more  quickly  and  adroitly  than  a  skilled  operator. 

To  produce  a  bodily  distal  movement  of  the  left  lower  cuspid,  root-wise  labial 
and  lingual  bars  were  soldered  to  the  cuspid  band  with  hook  attachments  for 
elastics  to  extend  to  root-wise  attachments  on  the  anchorage.  To  further  insure 
and  sustain  a  bodily  movement  of  the  cuspid,  a  small  tube  was  firmly  soldered 
to  the  cuspid  band  which  telescoped  into  the  anchorage  tube  with  an  easy  sliding 
movement.  This  is  not  distinctly  shown  on  account  of  the  position  of  the  elastics. 
The  arch-bow  passed  through  these  tubes  to  engage  with  a  distal  nut.  This  is  one 
of  the  common  methods  in  the  author's  practice,  either  with  elastic  or  screw  force, 
for  closing  spaces  after  the  extraction  of  buccal  teeth,  by  a  bodily  disto-mesial 
movement  of  the  adjoining  teeth. 

One  of  the  most  important  and  effective  auxiliaries  in  the  correction  of  this 
character  and  every  form  of  open-bite  malocclusion  which  demands  an  extrusive 
and  lingual  movement  of  the  lower  front  teeth,  is  the  occipital  force.  (See  "Open- 
bite  Malocclusion,"  Chapter  XXVIII.) 


CHAPTER  XXVIII 

Type  G,  Division  1,  Class  I 

OPEN-BITE   MALOCCLUSION 


Fic.  150. 


The  above  is  a 
in  open- 


common  facial  expression 
■bite  malocclusion. 


Fig.  1.51. 


Diagnosis 


In  the  malocclusion  which  is  characterized  by  open- 
bite,  the  front  teeth  are  apart  or  open  when  the  jaws 
are  closed  in  an  effort  to  masticate  food.  The  extent 
of  the  malocclusion  varies  in  its  scope  from  conditions 
in  which  only  the  most  distal  molars  occlude,  to  condi- 
tions in  which  all  of  the  buccal  teeth  may  quite  per- 
fectly occlude  while  the  labial  teeth  are  apart.  In 
pronounced  cases  of  open-bite,  when  the  jaws  are  in 
their  nearest  occlusal  relations,  with  the  lips  in  repose, 
the  mouth  is  usually  open,  often  with  a  drooping  of  the 
lower  lip,  which  even  with  patients  of  more  than  com- 
mon intellectuality,  often  produces  the  expression  of 
imbecility.  See  Fig.  150.  Again,  the  forced  effort 
to  close  the  lips  in  these  cases,  especially  if  complicated 
with  bimaxillary  protrusion,  will  retract  and 
retrude  the  muscles  of  the  chin  and  give  to  the 
features  an  awkward  receding  chin  effect,  which 
enhances  the  deformity,  as  shown  in  Fig.  151. 

The  occluso-labial  casts  of  a  few  typical 
characters  of  open-bite  malocclusion  are  shown  in 
Fig.  152.  The  impressions  for  these  cases  were 
taken  by  pressing  modeling  -  compound  against 
the  teeth  while  the  jaws  were  as  fully  closed  as 
possible.  Fig.  153  shows  on  the  right  a  common 
result  after  treatment. 

Occasionally,  the  condition  obtains  far  more 
upon  one  side  than  upon  the  other.  Usually, 
however,  the  space  between  the  upper  and  lower 
teeth  quite  uniformly  increases  from  the  point  of 
occlusion  toward  the  front,  just  as  if  the  mandible 
had  been  bent  downward  or  straightened  at  the 
angles  of  the  rami.  In  fact,  in  pronounced  cases 
227 


228 


FART    17.     DENTO-FACIAL  MALOCCLUSIONS 


where  only  two  or  more  molars  on  each  side  occlude,  the  back  ones  will  at  times 
seem  to  have  been  driven  into  their  sockets  throuj^^h  the  {(jrce  of  mastication,  or 
prevented  from  growing  to  their  full  height,  so  that  the  tuberosities  come  into 
close  proximity  to  the  angles  of  the  rami  when  the  jaws  are  closed. 

The  author  has  met  with  a  number  of  cases,  however,  older  than  twenty-five 
years  of  age,  where  the  entire  forces  of  mastication  had  been  sustained  from  child- 
hood by  single  molars  on  each  side,  with  no  apparent  intrusive  movement. 


Fig   152. 


Notwithstanding  the  fact  that  this  irregularity  is  the  sole  characteristic  of 
many  pronounced  dento-facial  deformities,  it  nevertheless  cannot  be  classified  as 
belonging  to  any  particular  one  of  the  three  dento-occlusal  classes  of  malocclusion 
for  the  reason  that  it  arises  in  every  character  of  disto-mesial  occlusion  of  the  buccal 
teeth,  and  consequently  in  every  class. 

Fig.  1.53. 


Unfortunately  a  few  orthodontists  in  their  writings  have  denominated  this 
character  of  malocclusion  as  cases  of  infra-occlusion ;  while  others  quite  as  earnestly 
believe  that  they  are  cases  of  supra-occlusion ;  whereas,  the  fact  is,  while  some  of 
the  cases  are  due  to  an  infra-occlusal  position  of  the  front  teeth,  and  others  are  due 
to  a  supra-occlusal  position  of  the  back  teeth,  the  greater  number  are  due  to  neither 
one  nor  the  other,  but  to  a  maldevelopment  of  the  mandible  in  which  the  rami 
and  body  of  the  mandible  have  assumed  a  more  obtuse  angle  than  is  normal, 
and  which  consequently  prevents  the  occlusion  of  the  front  teeth. 

In  order  to  arrive  at  an  appreciation  of  the  causes  of  open-bite  malocclusion, 
it  would  be  well  to  remember  that  the  terms  "supra  and  infra-occlusion,"  are 


CHAPTER   XXVIII.     TYPE  G.     DIVISIOX   1.     CLASS  I.  229 

merely  relative  terms,  like  distal  and  mesial,  labial  and  lingual,  etc.,  that  are 
employed  to  define  malpositions  or  movements  in  relation  to  the  normal  or  typical 
standard  line  of  occlusion.  The  typical  line  of  the  occlusal  plane  is  that  which 
may  be  said  to  arise  when,  with  dentures  in  normal  occlusion,  and  the  lips  of  es- 
thetic facial  outlines  in  perfect  repose,  the  incisal  edges  of  the  upper  front  teeth  are 
even  with,  or  very  slightly  below,  the  parting' of  the  lips,  though  the  curve  of  the 
lower  occlusal  plane  candies  its  labial  portion  slightly  above  this. 

There  are  people  on  every  hand  with  normal  occlusions,  and  with  apparently 
no  dental  irregularity,  who  cannot  close  their  lips  without  an  awkward  and  de- 
forming effort,  and  when  they  are  laughing  or  talking,  the  entire  crowns  of  the  front 
teeth  are  not  only  exposed,  but  the  gums  far  above  are  in  decidedly  unpleasant  evi- 
dence, and  solely  because  the  dentures,  both  front  and  back,  upper  and  lower, 
are  in  a  supra-occlusal  position  in  relation  to  a  typical  dento-facial  occlusal  plane. 
In  many  of  these  cases,  the  lips  would  reposefuUy  close  with  perfect  dento-facial 
outlines  if  all  the  teeth  could  be  proportionately  intruded.  The  fact  that  we  at 
times  see  this  condition  running  through  whole  families,  proves  the  cause  to  be 
that  of  heredity. 

On  the  other  hand,  the  dentures  are  frequently  in  the  opposite,  or  infra-occlusal 
malposition.  Occasionally  this  is  so  pronounced  that  it  amounts  to  a  facial  de- 
formity. This  does  not  refer  to  those  frequent  close-bite  malocclusions  commonly 
found  in  Class  II,  in  which  the  lower  front  teeth  strike  into  the  gums  back  of  the 
upper,  but  with  the  incisal  edges  even  with  the  lips  when  the  jaws  are  apart,  and 
which  can  only  be  due  to  an  infra-occlusal  position  of  the  back  teeth,  but  it  refers 
to  cases  in  which  both  the  front  and  back  teeth  are  in  an  infra-occlusal  position  in 
relation  to  the  typical  dento-facial  occlusal  plane,  shown  by  the  fact  that  the  occlusal 
edges  of  the  front  teeth  are  in  a  marked  intrusive  position  in  relation  to  a  reposeful 
parting  of  the  lips,  and  also  by  the  fact  that  when  the  jaws  are  closed  in  masti- 
cation, the  lips  in  contact  are  forced  forward  with  a  marked  redundancy  of  lip 
tissue.  This  character  is  illustrated,  and  its  treatment  described  in  connection 
with  Close-bite  Malocclusions,  in  Concomitant  Types  of  Class  II. 

Causes 

Many  cases  of  open-bite  malocclusion  vmdoubtedly  arise  from  some  form  of 
heredity.  This  is  proven  in  families  in  which  some  one  or  more  of  the  children 
duplicate  the  exact  peculiarities  of  the  teeth,  with  an  open-bite  which  obtained 
with  one  of  the  parents  or  grand-parents.  One  of  its  most  common  inherited  forms 
is  that  which  is  occasioned  by  a  supra-occlusion  of  the  back  teeth.  This  is  well 
illustrated  in  Fig.  151. 

The  most  prolific  sources  of  open-bite  malocclusion,  however,  are  from  local 
causes.  There  are  three  quite  distinct  kinds,  all  of  which  arise  from  different 
characters  of  local  causes  operating  during  the  early  years  of  childhood  develop- 
ment.   In  the  first  kind,  the  front  teeth  are  in  an  infra-occlusal  malpo.sition,  caused 


230  PART    VI.     DENrO-FACIM.   MALOCCLUSIONS 

by  the  early  habits  of  tonj^ue,  hp,  cheek,  and  thumb-sucking,  and  in  fact  any  post- 
natal cause  which  tends  to  retard  or  inhibit  the  normal  growth  development  of  the 
erupting  permanent  teeth.  These  habits  no  doubt  start  during  the  irritating  periods 
of  dentition,  because  of  the  relief  afforded  in  biting  upon  some  resisting  tissues,  or 
resilient  substances  of  which  rubl)er  rings  and.  so  called  "pacifiers"  have  played  a 
more  or  less  active  part. 

The  second  and  third  kinds  are  produced  by  a  malformed  development  of  the 
mandible  itself  which  forces  the  dentures  into  an  open  malocclusion.  In  the 
second  kind  the  mandible  is  forced  to  one  side  with  the  production  of  a  decided 
lateral  malocclusion,  and  with  an  open-bite  which  often  extends  from  the  most 
distal  molar  upon  one  side  to  the  premolars  upon  the  other.  This  character  is  fully 
described  in  the  previous  chapter. 

The  third  kind  arises  from  that  most  prolific  of  all  the  local  causes  of  mal- 
occlusion, i.  e.,  adenoids  and  enlarged  tonsils,  causing  partial  or  complete  stenosis 
of  the  nasal  air  passages,  resulting  in  mouth-breathing;  open-bite  malocclusion; 
inhibited  development  of  the  maxillae ;  tipper  retrusions ;  and  prognathic  mandibles. 
All  of  these  conditions  at  times  occur  in  one  case.  The  direct  cause  of  the  open- 
bite  is  through  the  mechanical  forces  of  the  muscles  acting  upon  the  early  develop- 
ing mandible  in  mouth-breathing,  mostly  during  the  long  sleeping  hours.  This 
character  of  open-bite  is  so  intimately  associated  with  malocclusions  of  Class  III, 
arising  as  it  does  from  the  same  local  cause  which  produces  some  of  the  principal 
characters  of  that  class,  the  modus  opennuli  of  its  cause  and  its  complete  practical 
treatment  will  be  found  under  Division  4  of  that  Class. 

Treatment 

In  those  cases  when  the  open-bite  is  due  to  an  infra-occlusal  position  of  the 
incisoi'S,  they  can  usually  be  easily  corrected  for  young  patients  with  a  light  re- 
silient arch-bow,  providing  the  cuspids  are  fully  erupted  and  will  stand  the  reaction 

Fic.  l.-)4. 


A 


of  this  force.  (See  Fig.  233.)  When  the  open-bite  involves  the  cuspids  and  other 
more  distal  teeth,  the  most  effective  correcting  medium  is  direct  intermaxillary 
elastics.      In  Chapter   XX,   "Modern  Principles  and  Methods  in    Orthodontia," 


CHAPTER  XXVIII.     TYPE  G.     DIVISION   1.     CLASS  I.  231 

is  shown  the  effectiveness  of  the  "Midget  Apparatus"  in  correcting  an  open-bite 
malocckision,  largely  through  the  medium  of  intermaxillary  elastics  which  are 
attached  to  specially  designed  bracket  attachments  which  also  support  a  very 
light  resilient  arch-bow. 

When  the  infra-occlusion  commences  with  the  premolars,  and  evenly  opens 
the  bite  toward  the  front,  a  No.  22  arch-bow  (.025")  may  be  effectively  employed 
with  spurs  for  the  elastics  attached  to  the  bow,  as  shown  in  Fig.  154.  With  this 
arrangement,  the  force  of  the  elastics  is  distributed  evenly  to  the  teeth  through 
the  medium  of  the  bow. 

For  older  patients,  with  longer  standing  pronounced  cases  of  open-bite  mal- 
occlusions, the  correction  and  retention  is  attained  with  far  greater  difficulty. 
The  causes,  extent,  and  peculiarity  of  the  malocclusion,  together  with  the  compli- 
cations which  are  commonly  present,  must  always  govern  the  treatment,  which 
will  depend  largely  upon  the  skill  and  ingenuity  of  the  operator,  and  his  ability  to 
cut  loose  from  stereotyped  commercial  appliances  for  those  which  are  individually 
constructed  to  meet  the  demands  of  the  case  in  hand. 

In  pronounced  cases  caused  by  mouth-breathing,  when  only  one  or  two  molars 
on  each  side  imperfectly  occlude,  it  is  generally  advisable  to  freely  grind  the  oc- 
cluding surfaces  (of  the  molars)  in  connection  with  the  regulating,  to  increase  as 
far  as  possible  the  area  of  occlusion  and  then  correct  the  rest  of  the  open-bite  with 
extensive  movements. 

Fig.  1.55. 


As  many  of  these  cases  in  practice  will  be  found  complicated  with  retruded 
upper  dentures  and  maxillae  in  Class  III,  demanding  a  bodily  labial  movement  of 
the  upper  front  teeth,  in  connection  with  a  protruded  mandible,  demanding  a  lin- 
gual movement  of  the  lower  front  teeth,  it  has  been  found  that  the  intermaxillary 
and  occipital  auxiliary  forces  are  of  the  greatest  possible  value  in  closing  the  open- 
bite  as  an  aid  to  the  general  correction.  Fig.  155  is  designed  to  show  the  appli- 
cation and  direction  of  the  intermaxillary  and  occipital  forces  employed  solely 
for  a  retruding  and  extruding  movement  of  the  lower  front  teeth.  In  those  cases 
where  the  upper  dentvire  is  in  normal  dento-facial  relations,  a  bow  (No.  .036  ) 
similar  to  the  one  shown  is  indicated  to  offer  a  static  resistance  to  the  forces. 
In  nearly  all  cases  of  this  character,  however,  the  upper  will  demand  the  bodily 
labial  movement  apparatus,  described  in  Class  III. 


CHAPTER   XXTX 

Division  2,  Class  I 
BIMAXILLARY   PROTRUSION   AND   RETRUSION 

Between  the  extreme  boundaries  of  Bimaxillary  Protrusion  and  Bimaxillary 
Retrusion,  which  are  diagrammatically  iUustrated  in  Fig.  156,  lies  every  gradation 
of  these  two  pronounced  characters,  which  merging  toward  each  other  should 
result  in  a  composite  of  typically  perfect  occlusion  and  facial  outlines.  There  is 
probably  no  dento-facial  malocclusion  which  so  frequently  arises  to  mar  or  deform 

Fig.  156. 


/ 


the  perfect  human  face  as  some  gradation  of  these  two  characters,  particularly 
that  of  the  protrusions.  Of  the  many  people  we  meet  whose  faces  are  denominated 
as  plain  or  homely,  if  their  facial  outlines  were  analyzed  from  an  artistic  stand- 
point, a  very  large  proportion  would  be  found  due  to  a  partial  or  full  protrusion  or 
retrusion  of  both  upper  and  lower  lips  in  relation  to  the  rest  of  the  features,  and 
caused  by  some  degree  of  protrusion  or  retrusion  of  the  dentures.  As  the  largest 
majority  of  these  are  stamped  with  the  lesser  degrees  of  these  characters,  and  as 

232 


CHAPTER  XXIX.    DIVISION  2.    CLASS  I.  233 

the  most  of  them  have  a  typically  normal  occlusion,  no  one — or  at  least  very  few — 
ever  thinks  of  correction  by  orthodontic  methods,  even  though  the  faces  of  many 
could  be  made  beautiful  by  a  very  slight  movement  of  the  teeth. 

Though  mvich  has  been  published  by  the  author  within  the  past  fifteen  years 
in  regard  to  bimaxillary  protrusion,  the  great  majority  of  the  Angle  school  ortho- 
dontists are  very  reluctant  in  recognizing  it  as  belonging  to  the  orthodontic  depart- 
ment of  practice,  because  its  correction  demands  the  extraction  of  teeth  and  the 
consequent  breaking  down  of  their  ideal  normal  occlusion.  They  seem  to  fear  that 
if  they  let  down  the  bars  in  one  place  in  their  teaching  they  will  have  to  in  other 
places  where  extraction  is  equally  imperative.  There  are  many  well  meaning 
skillful  orthodontists  who  feel  perfectly  justified  in  not  acknowledging  publicly  their 
belief  in  and  practice  of  rational  extraction,  not  wishing  to  set  an  example  to  the 
younger  members  of  this  specialty,  feariiig  they  might  too  freely  employ  it  in  prac- 
tice, while  others  secretly  and  extensively  practice  extraction  where  they  believe 
it  is  demanded  for  the  best  dento-facial  rcstxlts.  And  yet  many  of  these  orthodon- 
tists will  not  acknowledge  it  at  their  meetings  or  even  to  each  other,  seeming  to 
fear  they  will  be  ostracized  or  something,  not  realizing  that  nine  out  of  ten  of  the 
others  are  doing  the  same  thing. 

Some  of  the  older  members  of  the  dental  profession  can  remember  that  amal- 
gam for  filling  teeth  was  at  one  time  subjected  to  the  same  kind  of  unreasonable 
opposition,  and  wholly  due  to  a  few  leading  spirits  who  persistently  and  vehemently 
denounced  its  use,  being  justly  actuated,  no  doubt,  by  the  inexcusable  abuse  of 
amalgam,  the  same  as  many  orthodontists  have  been  and  are  actuated  by  the 
abuse  of  the  principles  of  rational  extraction.  The  time  is  now  fast  approaching 
when  a  clearer  understanding  will  show  the  ultimate  futility  of  all  attempts  to 
retard  the  true  question  of  extraction  as  in  all  truths  which  tend  toward  true 
progress. 

Bimaxillary  Protrusion  in  its  pronounced  form  is  one  of  the  most  facially 
deforming  characters  of  malocclusion  which  comes  into  the  range  of  dento-facial 
orthopedia.  It,  moreover,  is  the  only  character  in  that  large  diversified  Class  I 
which  does  not  arise  in  other  Classes.  As  it  has  been  erroneously  considered  by 
many  to  be  of  very  rare  occurrence,  and  its  correction  not  within  the  province 
of  orthodontia,  considerable  space  is  given  to  this  division  with  the  hope  that  it 
will  become  more  fully  recognized  and  regarded  according  to  its  true  importance 
and  possibiUties  of  correction.  In  Chapter  VII,  "Etiologic  Influences  of  Heredity," 
will  be  found  an  interesting  consideration  of  a  number  of  variations  of  heredity 
which  probably  have  been  and  are  productive  of  this  character  of  dento-facial 
malocclusion  in  its  difterent  degrees  of  prominence.  The  possibility  that  Men- 
del's Law  may  be  an  important  factor  by  which  this  and  other  types  of  dento- 
facial  malocclusion  arise  spontaneously,  as  it  were,  from  forebears  in  whom  no  such 
condition  has  ever  before  occurred,  will  solve  many  heretofore  mysterious  prob- 
lems of  etiology. 


234  PART    VI.     DEXTO-FACIAL   M MXK'CI.IJSIONS 

The  fifteen  pronounced  cases  of  bimaxillary  protrusion  shown  in  Figs.  157 
and  158,  arose  in  the  author's  practice  between  the  years  1900  and  1912.  This 
personal  record  of  the  marked  cases  of  this  character,  however,  hardly  begins  to 
represent  the  comparative  number  of  these  cases  found  among  the  mixed  types  of 
the  white  race.  An  observing  expert  at  cjuick  diagnosis  of  facial  outlines  will  see 
them  everywhere,  in  the  cars  and  crowded  thoroughfares  of  cities,  with  physiog- 
nomies characterized  by  protruding  mouths  and  receding  chins.  The  reason  why 
persons  of  this  type  do  not  seek  more  often  for  correction,  though  they  may  be 
perhaps  embarrassingly  conscious  of  their  facial  imperfection,  is  that  most  of  them 

Fi(..  ir,7. 


do  not  imagine  that  any  operation  is  possible.  Moreover,  their  dentures  are  so 
frequently  in  normal  occlusion  that  even  dentists,  whose  thoughts  are  engaged 
in  saving  teeth,  upon  seeing  these  seemingly  perfect  relations,  give  little  thought  to 
the  facial  aspect  which  the  dentures  produce;  or,  if  they  think  of  it  at  all,  they  re- 
gard these  patients  as  more  or  less  exceedingly  homely,  as  God  or  inheritance 
made  them.  The  same  is  true  of  many  modern  orthodontists  who  would  not 
consider  for  a  moment  the  extraction  of  teeth  from  mouths  in  which  the  dentures 
are  already  so  nearly  or  quite  in  normal  occlusion,  and  who  will  doubtless  tell 
you  that  all  that  is  necessary  in  these  cases  is  to  widen  the  arches  and  retrude  the 
front  teeth.  While  this  might  result  in  a  partial  improvement  in  the  facial  out- 
lines, the  teeth  would  always  remain  in  unpleasant  evidence,  with  an  awkward, 
strained  management  of  the  lips,  and  in  a  very  large  proportion  of  cases,  little  or 
no  correction  is  possible  in  that  way.  It  is  a  pity  to  think  these  patients  should 
be  allowed  to  go  through  life  in  that  way  when  perfect  correction  of  the  facial 
outlines  is  a  comparatively  easy  and  sure  operation  by  extracting  the  first  pre- 


CHAPTER  XXIX.    DIVISION   2.    CLASS  I. 


235 


molars  and  placing  the  remaining  buccal  teeth  in  normal  occlusion,  and  retruding 
all  the  labial  teeth. 

Unfortunately,  this  type  is  not  at  present  fully  recognized  by  the  strict  adherents 
of  the  Angle  system,  as  belonging  to  marked  malocclusions  which  demand  correc- 
tion, because  in  its  typical  form,  the  dentures  are  in  normal  occlusion.  Yet  if  there 
is  any  type  in  dental  orthopedia  which  demands  extensive  correction  when  it  occurs 
in  the  white  race,  it  is  this. 

Fin.  l.iS. 


When  these  cases  present  for  treatment,  especially  as  they  freciuently  do  after 
the  eruption  of  the  second  molars,  with  the  teeth  crowded  closely  together  in  arches 
of  nearly  or  quite  normal  width,  with  receding  chins,  and  decidedly  protruding 
lips  which  are  closed  with  difficulty  over  the  protrtiding  dentures,  every  competent 
orthodontist  must  see  that  there  is  no  way  to  correct  the  facial  outlines  of  these 
patients  by  an  orthopedic  movement  of  the  teeth  without  extraction. 

Special  attention  is  called  to  the  two  lower  cases  illustrated  in  Fig.  157  and  fully 
illustrated  in  Figs.  159  and  160.  In  the  case  shown  in  Fig.  159,  the  dentures,  with 
the  exception  of  a  slight  malposition  of  the  upper  right  lateral,  were  in  absolute 
normal  occlusion  and  normal  arch  width  and  alignment,  and  notwithstanding  the 
fact  that  four  premolars  were  extracted,  as  shown,  followed  by  the  application 
of  the  most  scientific  methods  of  correction,  the  dento-facial  protrusion  is  still 
not  wholly  reduced.  Think  what  misfortune  marred  this  patient's  girlhood  because 
she  did  not  receive  proper  treatment  until  after  twenty  years  of  age,  and  wholly 
because  the  occlusion  of  her  buccal  teeth  was  normal. 


236 


PART    VI.     DENTO-FACIAL   MALOCCLUSIONS 


Fig.  150. 


The  one  case  in  this  group  which  exhibited  a  marked  irregularity  from  a  normal 
occlusion,  is  shown  in  Fig.  160.  It  will  be  seen  by  carefully  examining  the  first 
facial  cast,  that  the  upper  lip  is  but  slightly  protruded,  which  is  explained  by  a 


Fig.  IGn. 


ABBA 


glance  at  the  overlapping  malpositions  of  the  upper  front  teeth,  contracting  the 
arch.  If  the  front  teeth  had  been  placed  in  arch  alignment  with  a  preservation  of 
all  the  teeth — the  buccal  teeth  being  already  in  normal  occlusion — the  result 


CHAPTER   XXIX.     DIVISIOX   2.     CLASS   I.  237 

could  not  have  been  other  than  a  further  protrusion  of  the  ah'eady  protruding 
lips,  with  an  increase  of  the  receding  chin  effect.  Upon  examining  the  finished  faces 
as  they  appeared  after  treatment — one  of  wliich  is  reproduced  from  a  photograph — • 
it  appears  as  if  there  had  been  a  forward  growth  of  the  mandible,  because  of  the 
greater  prominence  of  the  chin  and  the  almost  perfect  dento-facial  oiitlines,  but 
this  is  wholly  due  to  the  retrusive  movement  of  the  labial  teeth  and  the  harmonizing 
efTect  upon  the  facial  outlines,  made  possible  by  the  extraction  of  the  four  first 
premolars.  Soon  after  the  operation  was  completed,  the  young  man  graduated 
from  Princeton,  and  because  of  his  phenomenal  academic  ability  and  brilliancy, 
he  received  from  the  United  States  Government  an  important  diplomatic  appoint - 

Fig.  161. 


ment  abroad.  As  this  appointment  necessarily  entails  exacting  social  functions 
and  relations,  one  can  understand  his  appreciation  of  the  method  of  treatment  he 
was  finally  persuaded  to  adopt,  requiring  the  extraction  of  four  good  premolars, 
since  treatment  without  extraction  would  have  left  a  protruding  mouth,  prominent 
teeth,  and  a  receding  chin,  while  the  result  of  the  other  treatment  is  characterized 
by  comeliness,  self -poise,  and  intellectuality. 

In  the  group  of  ten  bimaxillary  protrusions  shown  in  Fig.  158,  it  will  be  seen 
that  they  present  the  same  marked  character  of  facial  outlines  as  the  former 
group.  Fig.  161  is  a  side  view  of  their  dentures  in  occlusion,  showing  the  same 
disto-mesially  normal  relations  of  the  buccal  teeth.  Only  the  right  side  is  shown, 
as  the  left  is  practically  the  same. 

Please  observe  the  face  on  the  lower  right  of  Fig.  158,  and  then  turn  to  Fig. 
162,  which  shows  every  view  of  the  casts  of  the  dentures  of  this  patient.  It  will 
be  .seen  that  they  are  quite  as  normal  in  occlusion  and  arch  widths  as  most  dentures 


238  PART    VI.     DEMO-FACIAL   MALOCCLUSIONS 

which  we  regard  as  normal.  But  when  we  compare  this  occlusion  with  the  physi- 
ognomy, we  can  then  full\-  appreciate  the  fallacy  of  the  teaching  that  "the  full 
complement  of  teeth  in  normal  occlusion  is  necessary  to  establish  the  most  pleasing 
liarniony  to  the  facial  (tutlines." 

Figs.  163  and  164  are  the  beginning  and  finished  faces  of  the  first  two  cases 
shown  on  the  left  at  the  top  of  Fig.  158.  They  will  serve  to  ilkistratc  the  common 
results  in  the  coiTection  of  this  character  of  bimaxillary  malocclusion,  performed 
after  the  preliminary  extraction  of  the  four  first  premolars.  The  photographs 
on  the  right  were  taken  several  years  after  these  cases  were  finished. 

Fic.  MV2. 


The  history  of  the  case  shown  in  Fig.  164  is  an  interesting  one  from  a  practical 
standpoint.  When  the  patient  presented  at  fourteen  years  of  age,  it  seemed  pos- 
sible to  correct  the  condition  without  extraction.  The  teeth  were,  therefore, 
placed  in  normal  occlusion,  as  shown  in  the  intermediate  dental  cast.  While 
the  protrusion  over  the  entire  dento-facial  outlines,  after  this  operation,  was  con- 
siderably increased  by  the  necessary  movement,  it  was  still  hoped  that  the  develop- 
ing growth  would  harmonize  the  relations.  But  after  waiting  about  one  year, 
and  still  finding  no  improvement,  and  wishing  to  have  time  to  properly  correct  it 
before  the  patient  started  a  course  in  an  Eastern  seminary,  her  parents  were  con- 
sulted, and  were  also  found  to  be  dissatisfied  with  the  result.  They  had  no  objec- 
tion to  the  extraction  of  the  four  premolars  if  it  promised  to  perfect  her  features. 


CHAPTER   XXIX.     DIVISION   2.     CLASS   I. 


239 


It  was  at  this  time,  when  the  patient  was  between  sixteen  and  seventeen  years  of 
age,  that  the  first  facial  impression  was  taken  from  which  the  facial  cast  that  is 
shown  on  the  left  was  made.  The  pictures  of  the  facial  and  dental  plaster  casts  on 
the  right,  which  show  the  finished  case  immediately  upon  its  completion,  do  scant 
justice  to  the  beauty  of  the  face  or  the  occlusion  of  the  teeth  which  obtained  later. 


Fig.  K 


In  an  extensive  practice,  one  will  be  called  upon  to  treat  every  gradation  of 
bimaxillary  protrusion  and  retru.sion  from  the  most  pronounced  types  to  those  of 
lesser  degree ;  and  one  will  understand  also,  how  this  type  gradually  merges  with 
unbroken  gradation  into  the  absokitely  normal,  with  beautiful  faces.  It  has  been 
observed  that  the  imperfections  in  the  facial  outlines  in  a  large  proportion  of  these 
cases,  pertain  almost  wholly  to  the  dento-facial  area  or  that  part  of  the  face  only, 
which  is  supported  and  characterized  by  the  relative  position  of  the  dentures  and 
alveolar  processes.  In  other  words,  the  general  labial  and  buccal  surface  outline 
of  the  dentures  constitute  the  framework  of  the  overlying  facial  contours.  It  is 
hoped,  therefore,  that  it  will  not  be  understood  that  dento-facial  harmony,  which 
is  the  composite  type  between  the  extremes  of  bimaxillary  protrusions  and  retru- 


240 


I'ART    VI.     ni-:\ TO-FACIAL   MALOCCLrSfOXS 


sions,  is  a  suri'  indication  of  normal  occlusion,  as  has  been  asserted  by  a  few  prom- 
inent writers,  an\-  more  than  normal  occlusion  is  a  sure  indication  of  dento- 
facial  harmon>-.  It  simply  means  that  the  framework  upon  which  the  soft  tissues 
of  the  face  rest  and  are  dependent  for  their  form  and  contour,  is  such  as  to  produce 
beauty  in  the  facial  outlines,  thout^^h  il  may  \)v  produced  1)\-  (|uite  irregular  teeth. 

Tliese  principles  are  well  illustrated  in  Fig.  165,  which  shows  on  the  left  and 
right,  types  of  jjronounced  bimaxillary  protrusion  and  retrusion,  with  a  perfect 

Fi(,.  I(i4. 


dento-facial  type  above;  and  yet  the  dentures  of  these  cases  are  far  from  normal 
in  occlusion,  and  in  the  central  case,  with  its  beautiful  face,  a  number  of  teeth  were 
missing,  because  of  germ  extinction. 

In  the  diagnosis  of  bimaxillary  protrusions,  the  same  rules  apply  as  in  the 
diagnosis  of  all  dento-facial  malocclusions.  The  occlusal  relations  of  the  dentures 
show  that  they  belong  in  Class  I.  The  true  relation  of  the  chin  is  determined  by 
excluding  from  the  vision  the  immediate  protruded  area  in  order  to  compare  it 
with  the  main  features  of  the  physiognomy.  The  relation  of  the  lower  lip  to  the 
chin,  denotes  that  the  lower  denture  is  protruded  in  relation  to  the  mandible,  and 
with  the  dentures  in  normal  occlusion  and  in  alignment,  the  upper  must  also  be 
equally  protruded  in  relation  to  the  mandible.  Therefore,  if  the  chin  is  in  normal 
relation  to  the  features  outside  of  the  dento-facial  area,  it  must  be  a  bimaxillary 
protrusion.  These  same  diagnostic  rules  are  applicable  in  the  reverse  to  bimaxillary 
retrusions. 


CHAPTER   XXIX.     DIVISIOX   2.     CLASS   I.  241 

Treatment 

Bimaxillary  Protrusion. — There  is  no  way  to  correct  the  facial  outHnes  in 
extreme  cases  of  bimaxillary  protrusion,  except  by  the  extraction  of  four  teeth,  two 
upper  and  two  lower,  preferably  -the  four  first  premolars,  unless  other  teeth  are 
considerably  broken  down  from  decay  and  cannot  be  permanently  saved.  After 
the  extraction  of  the  premolars,  the  front  teeth  are  retruded,  principally  from 
root -wise  stationary  anchorages,  in  the  same  manner  as  described  for  the  cor- 

FiG.  Ui5. 


1 

■ 

J^m 

^^^^^H 

c^^''^H 

^Kv                     ,,      ,  _^^^^^^^^^^B 

■■■ 

rection  of  upper  protrusions.  The  great  object  for  firm  stability  of  anchorages 
is  to  avoid,  as  far  as  possible,  a  mesial  movement  of  the  back  teeth  in  order  to 
enable  the  greatest  possible  retrusive  movement  of  the  front  teeth  to  correct  the 
facial  outlines. 

In  nearly  all  cases  which  the  author  has  observed,  the  protrusion  pertains 
mostly  to  the  coronal  zone,  and  therefore  does  not  often  reqtxire  a  bodily  retru- 
sive movement.  The  retruding  force,  however,  should  always  be  applied  at  the 
gingival  margins,  as  directed  in  Practical  Treatment  of  Full  Coronal  Upper 
Protrusions. 

In  the  disto-mesial  movement  of  buccal  teeth  to  close  spaces  of  extracted  teeth 
by  reciprocal  action,  or  from  a  stationary  anchorage,  the  employment  of  root-wise 
attachments  should  be  considered  indispensable  in  order  to  avoid  an  inclination 


242 


PART    VI.     Dh.STO-l'WCIAI.    MALOCCLUSIONS 


l(i<). 


movement  by  placing  the  action  of  Ihc  force  at  a  jjoint  nearer  to  the  center  of  al- 
veolar resistance,  as  has  been  fully  exi^lained  in  previtnis  chapters.  This  is  es- 
pecially important  in  closing  spaces  after  the  extraction  of  molars. 

Fig.  16(i  illustrates  a  case  of  I  )i maxillary 
protrusion  which  was  corrected  by  extract- 
ing the  four  first  molars  that  were  broken 
down,  probably  through  the  action  of  some 
eruptive  disease.  It  will  be  seen  that  the 
spaces,  except  on  the  right  lower,  were  all 
closed  in  the  completed  models  shown  by  a 
bodily  disto-mesial  movement  and  with  no 
tipping  of  the  adjoining  teeth.  The  cause 
of  the  space  between  the  right  lower  molar 
and  premolar  was  due  to  the  breakage  of 
the  appliance  on  that  side  during  a  summer's 
outing  in  a  boy's  camp.  This  was  soon 
corrected  with  a  special  appliance.  The 
impressions  for  these  illustrations  were  taken 
u]jon  his  return. 

In    all   cases   requiring   closure   of   wide 
spaces,    where   teeth    have    been   extracted, 
the  appliances  should  be  constructed  with  a 
view  to  produce  a  bodily  disto-mesial  move- 
ment and  prevent  those  aniioying  inverted 
V-shaped  spaces  that  always  otherwise  ob- 
tain.    Fig.   167   shows  one  of  the  common 
The  most  important  feature  is:  The  power 
The  power  bar  should  be  very  rigid  (No.  18 
spring  nickel  silver)  and  fitted  intf>  long-bearing  tube  attachments.     The  upper 

tube,  soldered  to  the  molar  band,  is  No.  19-28, 
and  telescopes  into  a  thin- walled  tube,  soldered 
to  the  premolar  band.  The  upper  and  lower 
tubes  must  move  exactly  parallel  with  each 
other.  The  arch-bow  (No.  19  spring  wire),  be- 
sides acting  as  a  retruding  force  upon  the  front 
teeth,  aids  in  sustaining  the  rigidity  of  relations 
between  the  molar  and  the  premolar  —  which  is  the  main  principle  of  this 
apparatus. 

Bimaxillary  Retrusions  are  far  more  rare  in  practice  than  bimaxillary  pro- 
trusions^ and  though  this  type  of  physiognomy  may  be  quite  frequently  observed 
among  people  we  meet,  there  is  no  reason  why  such  conditions  do  not  arise  from 
heredity,  the  same  as  decided  retrusions  of  a  single  denture  in  relation  to  the 


w  w 


methods  employed  for  this  purpose 
is  applied  from  root-wise  extensions. 


^\G.  107. 


CHAPTER   XXIX.     DIVISION  2.     CLASS  I. 


243 


remaining  features,  as  in  retrusion  of  the  lower  denture  in  Division  1,  Class  II — ■ 
and  retrusion  of  the  upper  in  Division  1,  Class  III. 

The  main  reason  why  these  cases  do  not  present  for  treatment  is  the  same  as 
that  which  prevents  the  presentation  of  bimaxillary  protrusions,  i.  e.,  because 
the  dentures  in  these  two  characters  are  in  normal  occlusion,  or  nearly  so,  and 
consequently  these  patients  are  rarely,  if  ever,  told  that  the  facial  outlines  can  be 
easily  and  greatly  beautified  by  a  labio-lingual  movement  of  the  front  teeth,  which 
can  be  as  easily  retained  as  retrusions  and  protrusions  of  single  dentures. 

Fig.  ItiS. 


mWW 


There  have  been  only  two  well  defined  cases  presented  for  treatment  in  the 
author's  practice.  One  of  these  is  shown  on  the  right  of  Fig.  165.  After  the  case 
was  started  some  years  ago,  the  family  moved  away,  and  the  treatment  of  the 
case  was  dropped. 

Fig.  168  shows  on  the  left  the  Ijeginning  facial  and  dental  casts  of  a  case 
which  has  been  recently  finished  in  the  author's  practice,  as  shown  on  the  right. 
It  will  be  seen  that  the  first  and  second  upper  and  lower  premolars  on  the  right 
side,  and  second  premolars  on  the  left  side  are  missing,  the  germs  being  extinct. 

The  main  thing  to  be  accomplished  in  this  case,  as  in  many  others  where 
several  permanent  teeth  are  missing,  is  the  correction  of  the  facial  outlines,  leav- 


244  PART    17.     DEXTO-FACI  AT.   M  A  I.OCCLVSIONS 

ing  the  teeth  iilLimatcly  in  a  jjosition  to  ]jcnnanciilly  siipi)(>rt  bridj^e  dentures  for 
occhision  and  retention.  The  treatment,  after  the  ahgnment  of  the  front  teeth, 
consisted  in  a  bodily  labial  movement  of  the  upper  and  lower  incisors,  utilizing 
the  force  of  the  reaction  of  the  fulcrum  bow  for  a  labial  movement  of  the  cuspids. 
One  of  the  most  important  parts  of  all  operations  where  considerable  bodily 
labial  movements  have  been  accomplished  for  the  correction  of  decided  retrusions, 
is  that  retaining  appliances  must  be  made  so  as  to  keep  up  the  bodily  tension  on  the 
roots  of  the  front  teeth  for  at  least  two  years  after  the  case  is  corrected.  This  is 
accomplished  with  the  usual  six-band  retainer  (see  Fig.  309,  Chapter  LV),  which 
carries  long-bearing  tubes,  into  which  is  inserted  threaded  spring  bars  which 
extend  to  open-tube  attachments  upon  molar  anchorages.  By  this  arrangement  the 
bodily  tension  is  kept  up,  and  the  labial  movement  can  be  continued  if  required. 


CLASS  II 

DISTAL   MALOCCLUSION   OF   LOWER   BUCCAL  TEETH 


Table  of  Divisions  and  Types 
DIVISION    1:     RETRUSION   OF  THE   LOWER   DENTURE 

Type  A:    pronounced  retrusion  of  lower  denture  with  upper  normal 
Type  B:     moderate  retrusion  of  lower  denture  with  protrusion  of  upper 

DIVISION    2:  PROTRUSION    OF   THE   UPPER   WITH   LOWER   NORMAL 

Type  A:  upper  coronal  protrusion 

Type  B:  upper  bodily  protrusion 

Type  C:  upper  coronal  protrusion  with  apical  retrusion 

Type  D:  upper  apical  protrusion  with  lingual  inclination 

Concomitant  Characters  of  Class  II 

retrusion  of  mandible  and  lower  denture 
close-bite  malocclusion 

MALERUPTION  of   cuspids      (See  Class  I,  Chapter  XXIV) 


CLASS  II 


CHAPTER  XXX 
INTRODUCTION   TO   CLASS   II 

In  distal  malocclusion  of  the  lower  buccal  teeth,  there  arise  several  Divisions 
and  Types  which  distinctly  differ  from  each  other  in  their  dento-facial  characters 
and  demands  of  treatment.  This  is  fully  outlined  in  the  chapter  upon  Dento-facial 
Diagnosis,  where  rules  for  determining  the  several  characters  of  dento-facial  mal- 
occlusion and  their  general  demands  of  treatment  should  be  carefully  studied. 

Fig.  169. 


The  fact  that  in  all  of  this  Class  of  malocclusions  the  upper  denture  is  far  in 
front  of  a  normal  occlusion  with  the  lower,  has  led  many  to  the  impression  that 
they  should  be  treated  all  alike,  whereas,  the  facial  outlines — which  are  the 
only  true  medium  of  diagnosis — tell  a  far  different  story. 

In  comparing  the  facial  outlines  of  the  main  characters  of  Divisions  1  and  2 
of  this  Class,  the  chin  in  all  the  Types  is  in  normal  dento-facial  relation,  or  nearly 

.  246 


CHAPTER    XXX.     INTRODVCTIOX    TO   CLASS   If 


247 


so.  In  Type  A  of  Division  1,  illustrated  on  the  left  of  Fig.  169,  the  lower  lip — 
particularly  the  labio-mental  area — is  decidedly  retruded  in  relation  to  the  chin; 
while  in  Division  2,  illustrated  on  the  right,  it  is  in  esthetic  outline.  In  Type  A 
of  Division  i,  the  upper  lip  is  not  materially  protruded,  if  at  all,  in  relation  to  the 
adjoining  facial  outlines;  while  in  Types  A  and  B  of  Division  2,  the  upper  lip  is 
decidedly  protruded. 

A  not  uncommon  Type  of  Class  II  is  a  retruded  position  of  the  chin  in  relation 
to  dento-facial  harmony.  This  always  emphasizes  the  facial  disharmony  and 
increases  the  difficulties  of  diagnosis  and  treatment  of  all  of  the  dominant  characters 

Fir,    17(1, 


with  which  it  occurs.  See  Fig.  170.  As  this  occurs  in  both  Divisions  1  and  2, 
it  is  placed  with  Concomitant  Characters  of  Class  II  where  the  general  principles 
of  treatment  will  be  found. 

As  one  advances  in  the  study  and  practice  of  orthodontia,  he  realizes  more 
and  more  fully  the  unreliability  of  depending  upon  the  disto-mesial  relations  of 
buccal  occlusion  as  a  basis  in  determining  the  character  and  treatment  of  mal- 
occlusions. This  is  most  perfectly  and  repeatedly  exemplified  in  Class  II  Mal- 
occlusions, which  are  characterized  dentally  by  a  pronounced  distal  malocclusion 
of  the  lower  denture  in  relation  to  the  upper.  But  in  a  dento-facial  diagnosis, 
the  different  characters  are  found  to  contain  every  gradation  in  character  which 
lies  between  the  extremes  of  a  pronounced  retrusion  of  the  lower  with  the  upper 
normal,  and  a   pronounced   protrusion   of  the  upper  with   the  lower  normal,   all 


248  PART    VI.    DENTO-FACIAL  MALOCCLUSIONS 

of  which  demand  variations  in  treatment  to  obtain  the  most  perfect  dento- 
facial  result. 

There  is  no  douljt  that  a  ku-ge  majority  of  malocclusions  of  Class  II  arise 
through  the  various  forces  of  some  form  of  heredity;  and  while  it  is  true  that  in  a 
large  proportion  of  cases  no  authentic  data  of  prenatal  causes  can  be  obtained  that 
would  give  rise  to  the  particular  character  in  question,  it  very  commonly  is  of  a 
Type  which  no  local  cause  could  have  produced.  On  the  other  hand,  there  are  a 
number  of  quite  pronounced  dento-facial  malocclusions  of  Classes  II  and  III  which 
arise  wholly  from  tonsillar  and  adenoid  influences,  and  again  from  other  more  directly 
acting  local  causes. 

In  Chapter  IV  is  described  the  modus  operandi  of  two  local  causes,  thumb- 
sucking  and  premature  loss  of  premolars,  both  acting  in  conjunction  during  early 
childhood  years  upon  an  inherited  normal  occlusion,  may  result  in  one  of  the  most 
pronounced  dento-facial  malocclusions  of  this  Class. 


CHAPTER  XXXI 

Type  A,  Division  1,  Class  II 
PRONOUNCED  RETRUSION  OF  THE  LOWER  DENTURE  WITH  UPPER  NORMAL 

F"^-  I'l-  In  the  common  inherited  form  of  Type  A,  Division  1, 

of  this  Class,  the  entire  lower  denture,  in  perfect  arch 
alignment  and  inclination,  is  in  a  pronounced  retruded 
position  in  relation,  not  only  to  a  normally  posed  mandible, 
but  also  to  all  the  other  features  of  the  physiognomy; 
the  upper  denture  being  in  normal  or  nearly  normal  dento- 
facial  relations.  By  an  examination  of  the  faces  shown  in 
Fig.  172,  which  represent  the  beginning  facial  and  dental 
casts  of  five  cases  in  practice,  it  will  be  seen  that  all 
have  the  same  peculiar  facial  expressions  which  mark 
this  Tj'pe,  and  when  once  recognized,  is  not  easily  for- 
gotten. Nor  is  it  always  an  unpleasant  expression, 
especially  if  there  is  sufficient  redundancy  of  lip  tissue  to 
prevent  a  too  conspicuous  appearance  of  the  upper  teeth. 
In  the  most  pronounced  retrusions  of  the  lower  denture 
where  the  mandible  is  not  also  retruded,  the  chin  will 
appear  to  be  too  prominent,  and  the  upper  more  pro- 
truded than  it  is,  because  of  the  immediate  retruded 
relation  of  the  lower  lip.  The  lower  lip,  in  its  habit  of 
repose  against  the  incisal  edges  of  the  upper  front  teeth, 
will  usually  be  curved  forward,  and  produce  a  defined 
lateral  crease  in  the  deepened  labio-mental  depression  marked  by  a  darkened  line 
of  stagnated  sebaceous  ducts,  commonly  known  as  "blackheads." 

On  the  right  of  Figs.  173  and  174,  are  fair  illustrations  of  the  common  results 
immediately  after  treatment  of  all  the  many  cases  of  this  character  in  the  author's 
practice.  But  it  is  a  regrettable  fact  that  the  disto-mesial  shifting  of  the  dentures 
to  a  normal  occlusion  in  these  cases,  as  shown,  can  very  rarely  be  retained  per- 
manently even  after  having  been  retained  artificially  in  that  position  for  two  years 
or  more.  In  fact,  when  this  particular  Type  is  treated  in  this  way,  there  are  no 
cases  in  the  author's  practice  that  are  as  difficult  to  permanently  retain,  or  more 
unreliable  in  the  long  run  in  the  production  of  that  perfect  satisfaction  which 
the  immediate  restilts  promise. 

The  principal  demand  of  treatment  to  correct  the  facial  outlines  is  a  bodily 
labial  movement  of  the  lower  front  teeth,  and  a  slight  lingual  inclination  movement 

249 


250 


PART    17.     DKNTO-l'ACJAL   MALOCCLL'SIONS 


of  the  ui)])er.  As  a  considerable  forward  movement  of  the  entire  lower  denture  and 
a  slight  retruding  movement  of  the  upper  can  be  easily  accomplished  with  young 
patients,  with  the  intermaxillary  force,  placing  the  dentures  in  normal  occlusion. 


Fig.  172 


it  is  this  particular  Type  in  which  this  metliod  of  force  has  seemed  to  be  especially 
applicable.     See  Fig.  127,  Chapter  XXI. 

The  surprising  possibility  of  a  reciprocal  disto-mesial  shifting  of  the  buccal 
teeth  to  a  normal  occlusion  was  the  one  thing  which  caused  the  Angle  school  of 
orthodontists  to  believe — as  many  of  them  still  believe  today — that  all  cases 
belonging  to  Class  II  malocclusions  should  be  treated  in  this  manner. 

Fig.  173. 


When  the  dentures  have  been  shifted  to  a  normal  occlusion  in  this  way  with 
the  intermaxillary  force,  notwithstanding  the  so-called  "locking  force"  of  normal 
occlusion,  they  are  usually  very  difificult  if  not  impossible  to  retain.  First,  because 
this  character  of  malocclusion  no  doubt  arises  from  a  strongly  marked  hereditary 
type,  or  the  admixture  of  inharmonious  types,  and  second,  because  retention  can 


CHAPTER  XXXI.     TYPE  A.     DIVISION   1.     CLASS   11.  251 

only  be  accomplished  by  the  employment  of  the  same  intermaxillary  forces  that 
were  employed  in  correction.  The  difficulty  of  moderating  this  force  to  the  exact 
degree  required  for  retention,  and  the  need  of  having  the  patient  attend  to  the  ad- 
justments presents  difficulties  that  at  times  are  insurmountable. 

This  is  true,  moreover,  in  this  method  of  correcting  all  disto-mesial  malocclu- 
sions of  the  bviccal  teeth  which  arise  from  heredity.  If  the  buccal  teeth,  through 
the  strong  forces  of  heredity,  have  assumed  that  position  in  relation  to  the  bones 
in  which  they  are  placed — whether  or  not  the  bones  themselves  partake  of  the 
malrelation — permanent  retention  of  any  extensive  movement  which  is  not  bodily 
and  interstitially  accomplished,  is  very  liable  to  result  in  failure. 

Fig.  174. 


These  principles  are  particularly  true  of  the  attempts  which  are,  and  have  been 
made,  to  correct  upper  protrusions  in  this  way;  and  it  no  doubt  is  largely  due  to 
this  that  so  many  orthodontists  have  discontinued  this  method  of  practice,  and 
adopted  the  more  rational  principles  of  extraction  in  these  cases. . 

In  Division  1,  however,  if  the  forward  movement  of  the  lower  denture  can  be 
fully  accomplished  before  the  eruption  of  the  second  molars,  there  will  be  a  far 
greater  chance  for  permanency  of  retention.  The  lower  denture  being  quite  de- 
cidedly retruded  in  relation  to  the  mandible,  it  is  reasonable  to  suppose  that  many 
instances  arise  in  which  the  second  and  third  molars  do  not  have  room  to  freely 
erupt.  Therefore,  if  the  first  molars  and  other  teeth  are  moved  mesially  and  bodily 
in  time  for  the  natural  development  and  eruption  of  the  second  molars  to  the  re- 
cjuired  mesial  position,  the  chances  of  permanency  of  retention  are  very  greatly 
increased. 

After  twelve  years  of  age,  and  at  times  before,  the  opening  of  interproximate 
spaces  for  the  insertion  of  artificial  lower  premolars  has  become  the  common 


252  PART   VI.    DENTO-FACIAL  MALOCCLUSIONS 

treatment  in  tlic  author's  practice  for  the  correction  of  nearly  all  Type  A  cases  in 
this  Division  of  malocclusions,  and  it  is  believed  that  it  will  prove  far  more  satis- 
factory than  the  extensive  disto-mesial  shifting  of  the  dentures  to  a  normal  occlu- 
sion. Nor  is  this  an  experimental  theory,  as  the  same  principle  has  been  thoroughly 
tried  out  and  its  value  tested  in  the  correction  and  retention  of  another  character 
of  malocclusion,  i.  e. — For  many  years  one  of  the  most  indispensable  methods  in 
the  author's  practice  in  the  correction  of  inherited  upper  retrusions  in  Class  III 
malocclusions,  has  been  the  opening  of  interproximatc  spaces  for  the  insertion  of 
buccal  teeth.  By  no  other  method  would  it  have  been  possible  to  retain  the  teeth, 
as  many  of  these  have  been  retained  for  years  with  no  apparent  tendency  to  return 
to  their  former  malpositions.  One  of  these  cases,  which  was  first  presented  before 
the  First  District  Dental  Society  of  New  York  City  in  1907,  is  illustrated  in  Fig. 
229,  Chapter  XLV. 

There  is  another  thing  which  has  appealed  to  many  orthodontists  of  late  in 
the  correction  of  pronounced  Type  A  malocclusions.  It  is  the  deniand,  from  an 
artistic  standpoint,  of  the  bodily  labial  movement  of  the  lower  front  teeth  to  produce 
a  more  perfect  contour  to  the  rctruded  labio-mental  area. 

The  apparattis  that  is  commonly  employed  for 
the  bodily  labial  movement  of  the  lower  front 
teeth  and  for  opening  interproximatc  spaces  be- 
tween the  premolars,  is  shown  in  Fig.  175.  The 
anchorages  in  this  case  are  on  the  first  and  second 
molars  and  second  premolars.  In  most  instances 
they  are  on  the  second  premolars  and  first  molars, 
and  in  complications  of  close-bite  malocclusions, 
they  are  on  the  single  first  molar  crowns  which  are  employed  to  open  the  bite. 
In  nearly  all  recent  cases,  moreover,  the  anchorage  power  tube  is  soldered  to  root- 
wise  extensions. 

In  cases  of  full  malinterdigitation,  the  forces  of  mastication  at  twelve  years  of 
age  and  later,  will  have  established  an  occlusion  that  is  sufficiently  needful  for  all 
physiologic  demands,  or  one  at  least  which  may  be  easily  adjusted  with  slight 
disto-mesial  and  bucco-lingual  movements.  If  in  these  cases  there  is  a  moderate 
protrusion  of  the  upper  denture  and  a  moderate  retrusion  of  the  lower  in  relation 
to  the  mandible,  the  correct  treatment  of  course,  would  be  to  shift  the  dentures 
to  a  normal  occlusion.  But  in  those  very  common  cases  in  which  the  dento-facial 
malrelation  is  due  wholly  or  nearly  to  a  rctruded  position  of  the  lower  denture, 
the  method  of  correction  which  gives  the  most  lasting  satisfaction  in  the  author's 
practice,  consists  in  a  bodily  labial  movement  of  the  lower  incisors  with  the  regular 
contouring  apparatus,  with  the  fulcrum  arch-bow  anchored  to  the  first  lower 
premolars  instead  of  the  molars.  This  arrangement  of  the  fulcrum  force  serves 
two  purposes,  i.  e.,  it  steadies  the  forward  movement  of  the  incisors,  keeping  them 
in  an  upright  position,  thus  aiding  the  power  arch-bow  in  moving  them  bodily 


CHAPTER  XXXI.     TYPE  A.     DIVISIOX   1.     CLASS  IT.  253 

forward.  At  the  same  time,  the  reaction  of  the  fulcrum  force  produces  a  mesial 
movement  of  the  cuspids  and  first  premolars,  opening  spaces  between  the  premolars 
for  artificial  retaining  teeth.  If  the  reaction  of  the  power  force  upon  the  stationary- 
anchorages  is  found  to  change  the  original  interdigitating  occlusion  of  the  buccal 
teeth,  they  should  be  supported  with  the  intermaxillary  force.  And  when  greater 
stability  is  demanded — as  frequently  occurs — the  tubes  should  be  soldered  to 
root -wise  extensions,  as  shown  by  numerous  illustrations.  This  method  results 
in  an  artistic  correction  of  the  facial  outhnes,  and  insures  permanency  of  reten- 
tion without  materially  changing  the  inherited  occlusion  of  the  buccal  teeth. 
See  Fig.  210,  Chapter  XLII. 

Fig.  176. 


Two  cases  of  twin  brothers,  commenced  at  twelve  years  of  age,  are  shown 
in  Figs.  176  and  177.  These  cases  were  practically  alike,  even  to  the  various 
malalignments  of  the  front  teeth;  therefore,  they  presented  a  most  favorable  op- 
portunity to  test  the  comparative  value  of  the  two  methods  of  correction.  That 
shown  in  Fig.  176  was  corrected  by  shifting  the  dentures  to  a  normal  occlusion 
with  the  intermaxillary  force,  being  careful  to  produce  a  much  greater  mesial  move- 
ment of  the  lower  than  a  distal  movement  of  the  upper.  That  shown  in  Fig.  177, 
was  corrected,  as  shown,  by  a  bodily  labial  movement  of  the  six  lower  front  teeth, 
the  first  premolars  being  carried  forward  by  the  force  of  the  fulcrum  arch-bow  of 
the  apparatus,  and  through  the  advantage  of  root -wise  attachments  on  the  premolars. 
When  this  movement  has  been  properly  retained  with  the  working-retainer  on  the 
lower,  and  the  spaces  are  finally  locked  with  the  extra  premolars,  as  shown,  there 
can  be  no  doubt  of  permanency  of  retention.  Whereas,  in  the  other  case,  like  many 
others  corrected  in  the  same  manner,  pcniunioicy  of  rcteiitioti  cannot  he  assured. 


204  J'Akl'    17.     I)E.\T()-FAC[M.    M A /.OCCf.L'.S/ONS 

It  is  not  usually  a  (lifficult  operation  to  shift  disto-mesial  malocclusions  of 
Class  II  to  a  normal  occlusion  with  the  intermaxillary  force  for  youthful  patients, 
l)rovidin<.^  there  are  no  pronounced  complications,  and  particularly  in  those  cases 
where  an  evenly  disposed  reciprocal  force  may  be  employed,  as  often  arises  in 
malocclusions  of  Type  A,  Division  1.  Nor  is  it  beyond  the  reach  of  most  ortho- 
dontists to  obtain  beautiful  results  at  the  close  of  operations  in  this  Type  by  this 
method,  even  where  considerable  complications  arise,  as  may  be  seen  in  the  illus- 
trations here  and  elsewhere  presented  in  this  work,  many  of  which  were  complicated 
with  close-bite  malocclusions.     But  that  is  not  the  whole  question  which  should  be 

Fig.  177. 


considered  in  the  advance  practice  of  orthodontia  of  today.  A  number  of  these 
same  cases  and  many  others  in  the  author's  practice,  and  no  doubt  hundreds  in 
the  practice  of  other  orthodontists,  have  not  retained  the  perfect  positions  shown 
by  the  finished  results,  even  after  being  artificially  retained  for  two  years  or  more 
with  the  most  approved  retaining  appliances.  Why?  Because  the  entire  upper 
and  the  entire  lower  dentures  have  been  moved  backward  and  forward  of  their 
inherited  positions  in  the  jaws,  and  particularly  because  there  are  no  stationary 
means  of  anchorage  by  which  they  can  be  reliably  held  in  the  corrected  position 
until  nature  can  establish  their  permanency  of  retention.  When  the  forces  of 
retention  are  confined  to  the  denture  in  which  the  movement  has  been  produced, 
the  degree,  direction,  and  continued  stability  of  these  forces  can  be  assured;  and 
this  is  ciuite  different  from  being  obliged  to  depend  upon  the  shifting  forces  of 
intermaxillary  elastics  in  the  employment  of  which  no  continuous  stability  of 
position  can  be  relied  upon. 


CHAPTER   XXXII 

Type  B,  Division  1,  Class  II 

MODERATE  RETRUSION  OF  THE  LOWER  DENTURE,  AND  PARTL^L  PROTRUSION 

OF   THE   UPPER 

In  following  the  rules  of  diagnosis  and  treatment  in 
Class  II  malocclusions,  if  the  chin  is  found  to  be  in 
normal  pose  in  relation  to  the  principal  features  of  the 
physiognomy,  and  the  lower  teeth  are  but  slightly  re- 
truded,  with  a  concomitant  deepening  of  the  labio- 
mental depression,  and  consequently  with  a  more  or 
less  pronounced  protrusion  of  the  upper  teeth  and  lip, 
as  shown  in  Fig.  179,  it  will  usually  be  advisable  to 
extract  the  first  or  second  upper  premolars,  with  the 
expectation  that  the  forces  required  to  retrude  the 
upper  labial  teeth  to  a  position  of  dento-facial  harmony 
will  so  react  upon  the  upper  buccal  teeth  and  all  the 
lower  denture  as  to  move  them  slightly  forward 
to  the  desired  degree,  and  completely  close  the  pre- 
molar spaces,  and  preserve  the  original  disto-mesial 
interdigitating  occlusion  of  all  the  buccal  teeth. 

It  will  be  seen  that  this  Type  differs  from  the  ordinary 
upper  protrusion  of  Division  2,  Type  A,  in  the  one  par- 
ticular that  the  lower  teeth  are  retruded.  This  can  only 
be  recognized  by  a  careful  study  of  the  facial  outlines. 
The  apparatus  indicated  for  the  upper  in  a  purely  Type 
B  character,  is  the  same  as  that  illustrated  and  described  in  Division  2,  and  chosen 
according  to  the  particular  Type  of  the  upper  protrusion,  always  being  careful  to 
arrange  for  the  application  of  the  several  forces,  as  has  been  fully  described — the 
appliances  always  being  constructed  to  retard  or  accelerate  the  forward  movement  of 
the  denture  in  proportion  to  its  degree  of  needs.  The  complete  apparatus  which 
the  author  has  found  most  commonly  applicable  in  these  cases  is  similar  to  Fig.  185, 

Chapter  XXXIV. 

Intermaxillary  Force 

The  intermaxillary  force  is  especially  applicable  in  all  reciprocating  disto- 
mesial  movements  of  the  buccal  teeth.  In  its  application,  great  care  should  be 
exercised  to  prevent  the  extrusion  of  the  molars — unless  this  movement  be  partic- 
ularly demanded,  as  in  close-bite  malocclusions. 

255 


256 


PART    17.     DKXTO-FACIAL   M ALOCCLL  SIGNS 


When  lliL'  second  molars  liavc  i'ully  erupted,  they  should  always  carry  the 
hooks  for  the  intermaxillary  elastics  instead  of  the  first  molars,  unless  an  extensive 
movement  of  the  buccal  teeth  is  demanded,  'i'lii'  im])orlant  ]jurpose  of  placing  the 
attachments  for  the  elastics  at  the  most  distal  jjoints  in  the  mouth  is  to  keep  the 
force  in  a  horizontal  or  mesio-distal  direction  as  much  as  possible.  If  it  is  necessary 
to  prevent  the  extruding  tendency  of  the  intermaxillary  force,  the  molar  attach- 
ments should  be  anchored  down,  so  to  speak,  and  in  such  a  way  so  they  will  not 

Fig.  179. 


materially  interfere  with  the  mesial  movement  in  view.  This  is  accomplished  by 
passing  the  lower  arch-bow  under  premolar  buccal  hooks. 

If  the  mesial  movement  of  the  lower  buccal  teeth  demanded  for  normal  occlu- 
sion is  not  more  than  one-half  the  width  of  a  cusp,  it  usually  may  be  accomplished 
for  youthful  patients  with  the  viltimate  preservation  of  occlusal  contact  of  the 
molar  planes.  That  is,  the  inclination  which  the  extent  of  the  movenient  at  first 
gives  to  the  molars,  will  ultimately  right  itself  if  properly  retained. 

In  the  chapter  upon  Principles  and  Technics  of  Retention  will  be  found  de- 
scribed methods  for  continuing  the  application  of  the  intermaxillary  force  long 
after  the  main  work  of  correction  is  accomplished.  This  appliance  is  frequently 
placed  even  before  the  normal  relation  of  the  buccal  occkision  is  attained. 

Cases  occasionally  arise  in  crowded  premolar  malalignments  for  which  it 
seems  desirable  to  utilize  all  of  the  intermaxillary  force  toward  a  labial  niovement 


CHAPTER   XXXII.     TYPE  B.     DIVISION   1.     CLASS  II.  257 

of  the  upper  or  the  lower  front  teeth,  with  httle  or  no  reciprocating  movement  of 
the  molars.  Besides  the  act  of  uniting  the  teeth  of  one  denture  so  as  to  retard  or 
prevent  a  disto-mesial  movement,  the  movement  of  the  other  denture  from  the 
same  force  may  be  increased  through  the  mechanical  advantage  of  applying  the 
force  to  a  few  teeth  at  a  time,  as  mentioned  elsewhere. 

Fig.  ISO.  In  Fig.  180  the  dental  arch-bow  (No.  18,  or  19, 

extra  hard)  engages  with  the  labial  teeth  by  means 
of  the  open-tube  attachments,  and  passes  under 
the  buccal  hooks  of  the  premolars,  and  then 
through  No.  18  tubes  on  the  first  molars;  the 
threaded  ends  finally  resting  in  telescope  or  slid- 
ing tubes  A,  within  tlie  anchor  tubes  B  on  the 
second  molars.  These  tubes  have  thin  walls 
(No.  32).  To  one  end  of  tube  A  (shown  dis- 
assembled), which  is  about  one-tenth  of  an  inch 
longer  than  the  attachment  tube  B,  is  soldered  a  hook  H,  as  shown,  for  the  attach- 
ment of  the  elastics.  The  ends  of  the  bow  are  threaded  to  carry  nuts  C,  D,  and 
E,  placed  as  shown.  When  the  apparatus  is  in  position,  the  nuts  C  and  D  are 
turned  back  against  the  sliding  tube  A,  forcing  it  back  until  the  hook  H  stands 
free  from  the  distal  end  of  the  anchorage  tube  B,  so  that  no  forward  pull  is  exerted 
upon  the  molars  when  the  intermaxillary  elastics  are  attached.  The  force  being 
directed  wholly  upon  the  arch-bow  through  the  medium  of  the  tube  A,  which 
engages  directly  with  the  nut  C,  the  labial  teeth  alone  to  which  the  bow  is  attached 
are  forced  forward ;  the  hooks  H  are  prevented  from  coming  in  contact  with  the 
tubes  B  by  means  of  the  nuts  C,  which  are  turned  back  from  time  to  time  as  the 
movement  progresses. 

When  the  labial  teeth  have  been  sufficiently  protruded,  the  premolars  are 
brought  forward  with  either  rubber  bands,  wire,  or  silk  ligatures  attached  to 
their  buccal  hooks  and  extended  from  one  side  to  the  other  around  in  front  of  the 
labial  teeth.  During  this  movement,  it  is  well  to  keep  the  nuts  C  and  E  pressing 
against  the  tubes  in  order  to  add  the  anchorage  force  to  that  of  the  intermaxillary. 
In  fact,  at  any  time,  the  two  forces  can  be  used  in  conjunction. 

When  the  premolar  position  is  corrected,  the  intermaxillary  force  is  directed 
to  the  mesial  movement  of  the  first  molars  by  turning  the  nut  D  forward  against 
the  distal  end  of  the  first  molar  tube,  and  the  nut  C,  as  before.  Finally,  the  second 
molars  are  brought  forward  with  the  intermaxillary  force  by  turning  the  nut  C 
forward  until  the  hook  H  attached  to  the  sliding  tube  A  engages  with  the  distal 
end  of  the  anchorage  tube  B. 

From  this  lengthy  description,  many  will  doubtless  think  that  this  is  quite 
a  complicated  operation.  Yet  the  construction  of  the  apparatus  requires  no  more 
skill — if  one  be  supplied  with  the  proper  material — than  others  that  appear  far 
more  simple.     When  the  apparatus  is  accurately  fitted  and  in  position,  the  fact 


2;)8  PART    VI.     DENTO-FACIAI.   MALOCCLUSIONS 

Ihat  it  contains  in  itself  all  the  elements  of  eonii)lete  and  successful  movements, 
the  subsequent  adjusiinj^r  treatments  are  reduced  to  the  minimum  of  time  and 
difllculties. 

The  combination  possesses  many  important  qualities:  the  horizontal  direction 
of  the  force,  together  with  the  rigid  quality  of  the  bow,  held  down  by  its  engage- 
ments to  all  the  buccal  teeth,  and  yet  permitting  a  distal  movement  along  its  sur- 
face, increases  the  stability  of  the  anchorage  against  the  extruding  tendency  of  the 
intermaxillary'  force  when  the  mouth  is  opened.  Again,  the  possibility  of  applying 
all  the  force  to  a  few  teeth  at  a  time,  and  means  being  provided  for  holding  the 
positions  gained,  while  others  are  forced  forward,  is  a  great  advantage. 


CHAPTER   XXXIII 

Division  2,  Class  II 

INTRODUCTION 

In  typical  upper  protrusions,  as  in  lower  retrusions.  the  upper  buccal  teeth  are 
always  in  mesial  malocclusion  with  the  lowers,  and  commonly  through  the  forces 
of  mastication  the  cusps  are  in  malinterdigitation,  or  fully  the  width  of  a  cusp  in 
front  of  a  normal  occlusion. 

While  it  is  true  with  this  character  of  malocclusion  that  the  lower  teeth 
are  frequently  in  a  more  or  less  retruded  position,  the  present  Division  will  be 
confined  to  the  description  and  treatment  of  the  several  Types  of  upper  protru- 
sions with  the  lower  normal,  and  determined  solely  by  the  rules  of  dento-facial 
diagnosis. 

The  author  is  fully  aware  of  the  close  relationship  which  this  Division  bears 
to  certain  Types  of  Division  1 ,  which  deal  with  the  same  character  of  malocclusion 
of  the  teeth,  but  which  relates  mainly  to  lower  retrusions.  As  the  two  Divisions, 
however,  represent  the  extremes  of  mesio-distal  malocclusion,  and  produce  dis- 
tinctively different  facial  outlines  in  character  and  treatment,  they  can  hardly 
be  considered  as  belonging  to  the  same  Division,  notwithstanding  the  almost 
indistinguishable  blending  of  intermediate  stages. 

Diagnosis  and  General  Rules  of  Treatment  of  Division  2. 

In  Diagnosis,  it  should  not  be  forgotten  that  with  upper  protrusions  the  chin 
will  appear  to  be  retruded  even  when  it  is  in  esthetic  relation  to  the  unchangeable 
features  of  the  physiognomy,  because  of  the  instinctive  tendency  to  compare  it 
with  the  immediate  malrelation  of  the  upper. 

If  the  upper  buccal  teeth  are  in  mesial  malinterdigitation,  as  shown  in  Fig.  181, 
and  the  lower  teeth,  lower  lip,  and  the  chin  are  in  esthetic  facial  relations,  the  char- 
acter of  the  irregularity  will  be  purely  that  of  an  upper  protrusion.  And  even  when 
the  lower  jaw  is  actually  retruded  (as  in  Concomitant  Characters  of  Class  II, 
described  in  Chapter  XXXVIII),  if  the  lower  teeth  and  lip  are  not  retruded 
in  their  relations  to  the  chin,  the  act  of  forcing  the  lower  teeth  forward,  to  aid  in  the 
production  of  normal  occlusion,  cannot  help  but  make  the  chin  appear  more  re- 
truded, tending  to  produce  a  receding  chin  effect,  which  is  always  to  be  avoided 
if  possible.  There  is  really  no  way  to  properly  correct  malocclusions  of  Division 
2  in  this  Class  other  than  by  extracting  upper  teeth — preferably  the  first  premolars. 
This  statement  pertains  not  only  to  the  correction  of  the  facial  outlines,  but  also 
to  that  most  important  of  all  objectives — permanency  of  retention. 

259 


260  PART    VI.     DENTO-FACIAL   M ALOCCHSIOXS 

Like  nearly  all  cases  which  jjossess  this  decided  disto-mesial  malocclusion, 
they  arise  through  some  form  of  heredity,  and  consequently  they  early  establish 
their  malinterdigitation  of  buccal  cusps.  In  those  cases  which  are  truly  diag- 
nosed as  upper  protrusions,  why  disturb  a  buccal  occlusion  (except  to  make 
slight  necessary  adjustments  laterally  and  disto-mesially)  which  answers  all  the 
purposes  of  mastication?  Frequently,  the  only  treatment  required  is  a  lingual 
inclination  movement  of  the  six  front  teeth,  and  the  case  is  ready  for  the 
retainer. 

By  the  other  method,  which  premises  that  no  teeth  should  be  extracted,  the 
case  is  supposed  to  be  corrected  by  shifting  both  dentures  disto-mesially  to  a  normal 
occlusion  with  the  intermaxillary  force.  Think  of  this  for  a  moment.  If  the  facial 
deformity  is  due  solely  to  a  protrusion  of  the  upper  denture,  as  it  is  likely  to  be, 

Fig.  ISl. 


the  perfect  correction  of  the  facial  outlines  can  be  accomplished  only  by  a  pro- 
portionate retnisivc  movement  of  the  entire  upper  denture.  Even  if  such  an  extensive 
movement  were  possible,  as  it  may  be  for  young  children, — provided  a  sufficient 
stationary  anchorage  can  be  established  to  prevent  the  lower  denture  from  moving 
forward — that  position  would  not  be  retained,  because  the  oncoming  second  and 
third  molars  would  in  all  probability  force  the  upper  denture  forward  again  to  its 
true  inherited  malposition. 

Such  an  extensive  distal  movement,  however,  is  probably  never  accomplished 
or  even  expected  in  the  usual  operation  of  shifting  the  dentures  to  normal.  What 
is  accomplished,  and  what  Dr.  Angle  advocated  as  his  method,  is  "to  move  the 
lower  mesially  one-half  the  width  of  a  cusp,  and  the  upper  distally  the  same  dis- 
tance, so  that  the  cusps  will  occlude  normally."  Nor  could  this  be  accomplished 
without  special  stationary  anchorages  on  the  lower — of  which  there  has  never  been 
a  record  in  that  system  of  practice — because  the  lower  would  otherwise  move  about 
twice  as  far  forward  as  the  upper  would  move  backward,  through  a  reciprocal 
action  of  the  intermaxillary  force.  Right  here  is  the  point  upon  which  the  whole 
question  of  this  method  of  treatment  hinges. 


CHAPTER  XXXIII.    DIVISION  2.    INTRODUCTORY  261 

With  any  forward  movement  of  the  lower  denture,  and  especially  with  an 
extensive  movement  which  that  system  of  treatment  portends,  with  the  lower  Up 
and  chin  already  in  normal  dento-facial  relation,  could  it  do  otherwise  than  abnor- 
mally protrude  the  lower  lip?  Therefore,  when  the  dentures  are  brought  to  a  normal 
occlusion  in  this  method  of  treatment,  the  upper  protrusion  may  be  less  than  one- 
half  corrected,  while  the  lower  is  reciprocally  protruded  to  an  equal  abnormal 
degree,  with  the  result  that  instead  of  correcting  the  facial  outlines,  a  bimaxillary 
protrusion  is  produced  with  probably  a  receding  chin  effect.  This  is  what  Dr. 
Cryer  meant  when  he  said  he  had  seen  a  number  of  these  cases  with  protruding 
mouths  right  from  the  hands  of  orthodontists  who  claimed  they  were  fully  cor- 
rected, and  that  statement — outside  of  the  author's  opinion — has  been  made  by 
many  others. 

Moreover,  the  frantic  efforts  to  reduce  decided  upper  protrusions  without 
extraction,  have  led  many  to  expand  upper  arches  to  such  an  abnormal  width  that 
the  buccal  teeth  were  in  unnatural  and  unpleasant  evidence.  It  is  true  that  many 
orthodontists  proudly  assert  that  they  correct  these  cases  dentally  and  dento- 
facially  without  extraction,  but  if  these  cases  to  which  they  referred  had  been 
correctly  diagnosed  at  the  start  from  an  artistic  standpoint,  they  would  have  been 
classified  as  lower  retrusions  of  Division  1,  Type  A  or  B. 

These  principles  here  enumerated  are  true  at  any  age  for  all  inherited  pro- 
nounced upper  protrusions.  And  as  mentioned  elsewhere,  they  have  reference 
also  to  the  early  disto-mesial  adjustment  of  the  first  permanent  molars  to  normal 
occlusion — a  practice  that  has  been  heretofore  extensively  advocated  for  all  disto- 
mesial  malocclusions  of  the  first  molars  of  children,  regardless  of  inherited  types. 


CHAPTER   XXXIV 

Type  A,  Division  2,  Class  II 

UPPER  CORONAL  PROIRUSTON 

A  common  form  of  upper  protrusion  is  that  which  is  cliaracterized  by  a  protrusion 
of  the  crowns  of  the  labial  teeth,  with  the  apical  zone  normal,  or  nearly  so.  This  is 
well  illustrated  in  Fig.  182.  By  an  examination  of  cases  of  this  Type  at  the  beginning 
of  the  operation,  it  will  be  seen,  first,  that  the  upper  buccal  teeth  are  in  decided  mesial 
malocclusion,  and  that  the  lower  lip  in  relation  to  the  chin  is  not  retruded  abnormally, 
which  excludes  the  case  from  Division  1  of  this  Class,  and  which  means  that  all  of 
the  antero-posterior  movements  of  the  front  teeth  for  the  correction  of  the  labial 

malposition  must  be  performed 
on  the  upper  teeth.  Second,  it 
will  be  seen  also,  that  the  upper 
part  of  the  upper  lip,  or  apical 
zone,  is  not  abnormally  pro- 
truded. In  fact  there  will  often 
appear  to  be  a  deepening  of  the 
naso-labial  lines  at  the  wings  of 
the  nose,  as  in  retrusions  of  the 
apical  zone  due  to  inhibited  de- 
velopment. While  the  diagnosis 
of  this  type  is  commonly  con- 
firmed by  an  abnormal  labial  in- 
clination of  the  front  teeth,  this 
must  not  be  taken  as  a  sure  indi- 
cation of  coronal  protrusion  or 
apical  retrusion,  because  even 
bodily  protrusions — in  which  the 
front  teeth  are  supposed  to  stand  in  a  normally  upright  position — will  at  times  have 
decided  labial  inclinations  of  the  incisors,  showing  that  surface  contours  of  the  face 
do  not  necessarily  follow  the  exact  lines  of  the  framework,  but  are  largely  regulated 
by  the  immediate  thickness  of  the  overlying  soft  tissues. 

If  the  crowns  of  the  upper  front  teeth  are  protruded  to  the  extent  of  a  full 
width  of  a  premolar,  the  first  premolars  should  be  extracted,  unless  the  second 
premolars  are  extensively  decayed.  Care  should  be  exercised  in  the  construction 
of  the  anchorages  and  the  application  of  forces,  so  as  not  to  move  the  back  teeth 
forward  and  thus  use  up  a  part  of  the  space. 

262 


CHAPTER   XXXIV.     TYPE  A.     DIVISIOX   2.     CLASS   11 


263 


The  dento-facial  correction  of  the  disto-mesial  maUnterdigitation  of  the  back 
teeth  in  this  Type,  which  will  often  be  found  in  perfect  masticating  occlusion, 
should  appeal  to  the  common  sense  of  all  orthodontists,  as  opposed  to  a  reciprocal 
movement  of  all  the  teeth  to  a  normal  occlusion,  to  say  nothing  about  the  correction 
of  facial  outlines  and  the  greater  possibilities  of  permanency  of  retention. 

Fig.  1,s:5. 


Fig.  184. 


Full  Upper  Coronal  Protrusion. — In  Fig.  183,  the  three-band  stationary  anchor- 
ages carr}'  two  buccal  tubes.  The  lower  tubes  are  for  No.  19  traction  bars  for 
retruding  the  cuspids,  and  as  shown  in  the  drawing,  they  are  soldered  at  the 
gingival  border  of  the  bands,  but  preference  is  given  to  the  root-wise  extensions 
previously  described.  The  upper  tube  is  for  a  No.  22  arch  traction  bow  for  retrud- 
ing the  incisors.  The  root-wise  position  of  both 
tubes  aids  in  the  stability  of  the  anchorage. 
The  upper  anchorage  tube  attached  to  the 
modern  root-wise  attachments  is  commonly 
the  one  chosen  to  move  the  cuspids,  as  shown 
in  Fig.  184.  See  Stationary  Anchorages,  Chap- 
ter X\'. 

An  important  feature  of  the  apparatus 
that  shcnild  never  be  omitted,  is  the  lingual  hooks  for  the  attachment  of  elastics 
to  prevent  the  rotation  of  the  cuspids  and  aid  in  their  retrusive  movement.     The 


264 


PART   VI.    DENTO-FACIAL  MALOCCLUSIONS 


open-tube  attaehments  on  the  ineisor  bands  are  of  very  thin  material  (20-30),  and 
when  these  are  properly  locked  around  the  small  wire  arch-bow  (No.  22),  with  all 
sharp  edges  removed  and  finished,  they  present  no  unpleasant  and  irritating  prom- 
inence to  the  lips.  The  labial  surfaces  of  the  incisor  bands  should  be  considerably 
narrowed,  and  if  they  are  of  nickel  silver,  they  should  be  covered  with  18k  gold 
solder,  and  this  with  the  small  size  of  the  arch-bow  aids  in  the  inconspicuousness 
of  the  apparatus. 

Fig.  185. 


When  any  doubt  arises  in  regard  to  the  stability  of  the  anchorages,  the  occip- 
ital and  intermaxillary  forces  should  be  employed.  In  nearly  all  cases  of  this 
Type,  the  occipital  force  with  post-rest  bow  A  is  indicated. 

Moderate  Upper  Coronal  Protrusion. — When  the  upper  buccal  teeth  are  in 
moderate  mesial  malrelation,  or  not  niore  than  one-half  the  width  of  a  cusp  in 
front  of  a  normal  occlusion,  occluding  "end  on,"  and  the  relation  of  the  lower 
lip  to  the  chin  is  one  that  will  not  bear  the  slightest  protruding  movement,  the 
extraction  of  the  second  premolars  is  often  indicated  for  patients  older  than  twelve 
years.  Frequently,  the  extraction  of  the  first  premolar  on  one  side,  and  that  of  the 
second  upon  the  other,  is  demanded,  because  of  the  dift'erence  in  the  mesio-distal 
occlusion  of  the  buccal  teeth.  When  the  malocclusion  is  bilateral,  with  a  moderate 
upper  protrusion,  be  careful  that  it  is  not  partially  a  lower  retrusion,  or  siifficicutly 
so  as  to  warrant  correction  with  the  intermaxillary  force  without  extraction. 


CHAPTER  XXXIV.    TYPE  A.    DIVISION  2.    CLASS  II.  265 

Fig.  185  is  designed  for  a  moderate  upper  protrusion  where  the  second  premolars 
have  been  extracted,  and  is  so  similar  in  its  construction  and  application  of  force 
to  the  apparatus  shown  in  Fig.  183,  it  will  be  imnecessary  to  further  describe  it 
here. 

In  moderate  upper  protrusions  with  partial  mesio-distal  malrelations  of  the 
buccal  teeth  of  children,  for  whom  there  is  no  positive  evidence  in  the  family  of 
inherited  upper  protrusion,  and  there  are  reasons  for  believing  that  the  mal- 
occlusion has  arisen  from  a  local  cause,  extraction  should  never  be  considered,  but 
the  correction  should  be  accompanied  by  a  distal  movement  of  the  upper  molars 
to  a  normal  occlusion,  to  be  followed  or  accompanied  with  a  retrusive  movement 
of  the  upper  front  teeth,  wholly  through  the  employment  of  the  intermaxillary 
and  occipital  forces. 


CHAPTER   XXXV 

Type  B,  Division  2,  Class  II 

UPPER    BODILY    PROTRUSION 

In  all  upper  bodily  protrusions  the  entire  maxilla  with  its  upper  denture  is 
protruded  or  prognathic  in  its  relation  to  the  other  bones  of  the  physiognomy. 
This  shows  conclusively  that  it  is  caused  from  some  form  of  heredity. 

In  diagnosis,  the  protrusion  of  the  upper  apical  dento-facial  zone  is  not  always 
at  first  recognized,  nor  can  this  be  determined  by  the  inclination  of  the  front 
teeth,  though  in  tipper  bodily  protrusions  the  front  teeth  are  more  likely  to  be  less 
labially  inclined  than  in  pronounced  coronal  protrusions  of  Type  A.  In  nearly  all 
typical  bodily  protrusions  of  Type  B,  however,  there  will  be  a  general  protrusion  of 
the  upper  lip  with  a  complete  obliteration  of  the  naso-labial  lines.  The  lower  lip 
and  chin  will  commonly  be  in  normal  pose,  the  whole  producing  an  expression  that 
is  quite  as  characteristic  of  this  malocclusion  as  the  peculiar  facial  expressions  of 
all  pronounced  protrusions  and  retrusions  are  characteristic  of  the  Types  and 
Classes  to  which  they  belong. 

For  patients  of  this  Type,  as  it  is  not  always  possible  to  determine  at  the  be- 
ginning of  the  operation  how  much  may  be  accomplished  by  applying  the  force 
at  the  gingival  margins  of  the  teeth,  the  regular  Contour  Apparatus  is  not  placed 
at  first  unless  a  decided  protrusion  of  the  roots  is  evident. 

Fig.  186  represents  one  of  the  most  common  and  effective  methods  in  the 
author's  practice  for  retruding  the  lal:)ial  teeth  after  the  extraction  of  the  first 
premolars. 

Its  construction  admits  of  the  application,  separately  or  in  combination,  of 
three  characters  of  retruding  force,  i.  e..  Stationary  Dental  Anchorage,  Occipital, 
and  Intermaxillary.  The  arch-bow  No.  19,  if  employed  with  the  hexagonal  lug- 
nuts  at  the  mesial  ends  of  the  cuspid  open-tube  attachments,  as  shown  in  the  dis- 
assembled apparatus,  may  be  made  to  exert  all  of  the  force  from  the  molar  anchor- 
ages upon  the  cuspids  alone,  or  it  can  be  equally  distributed  to  all  of  the  labial 
teeth  according  to  the  degree  to  which  the  cuspid  nuts  are  turned  in  proportion 
to  that  of  the  anchorage  nuts. 

The  force  is  applied  to  the  incisors  at  the  gingival  borders  by  means  of  exten- 
sions soldered  to  the  labial  surfaces  of  the  bands  so  that  the  arch-bow  will  span  the 
interproximate  gingivae.  If  it  is  desired  to  increase  the  force  upon  the  incisors,  or 
to  relieve  the  anchorage  force,  and  especially  if  an  intruding  force  is  demanded,  the 
occipital  force  may  be  employed  as  an  auxiliary  with  the  post-rest  bow  A  (See 
Fig.  78,  Chapter  X\T  ),  the  distal  nut  being  turned  only  to  take  up  the  slack  of  the 

266 


CHAPTER   XXXV.     TYPE  B.     DIVISION  2.     CLASS  II. 

Fig.  186. 


267 


268  PART   VT.    DENTO-FACIAL  MALOCCLUSIONS 

arch-bow.  The  intermaxillary  force,  with  shding  hookvS  engaging  directly  with  the 
retruding  arch-bow  through  the  medium  of  the  nuts,  is  invaluable  as  an  aid  in 
retruding  the  labial  teeth. 

Without  the  cuspid  nuts,  the  cuspids  may  be  retruded  with  the  intermaxillary 
force  as  shown,  and  supplemented,  if  desired,  with  the  occipital  force.  The  lingual 
hooks  upon  the  cuspids  are  for  elastics  to  the  lingual  molar  hooks,  which  will 
often  be  found  useful  to  control  or  increase  the  action.  It  will  be  seen  that  with  an 
intelligent  turning  of  the  four  nuts  upon  the  arch-bow,  the  intermaxillary  force 
can  be  directed  only  upon  the  molars,  the  cuspids,  or  the  incisors. 

As  the  apparatus  is  designed  for  Division  2  cases,  in  which  the  malocclusion 
is  entirely  due  to  a  protrusion  of  the  upper,  the  lower  teeth  are  quite  firmly  locked 
together  for  the  pm-pose  of  preventing  any  mesial  or  extruding  movement.  The 
lower  molars  carry  the  regular  two-band  stationary  anchorages,  which  can  be 
extended  to  the  premolars,  if  desired,  and  supplemented  with  root-wise  attachments. 
The  distal  intermaxillary  hooks  on  the  molar  anchorages  are  wide,  buccally  convex, 
and  are  attached  to  the  disto-occlusal  points.  The  premolars  and  labial  teeth  are 
firmly  attached  to  a  No.  19  or  20  arch-bow  by  means  of  hooks  and  open-tube  attach- 
ments; the  arch-bow  is  then  firmly  locked  to  the  molar  anchorages  with  mesial 
and  distal  nuts. 

The  intermaxillary  hooks  for  the  attachment  of  the  elastics  to  the  upper 
are  soldered  to  short  open  tubes,  which  slide  back  along  the  retruding  bow 
and  engage  with  the  attachments  on  the  cuspids. 

Fig.   187  is  presented  purely  to  show  a 

Fig.  1S7.  .      .  .  .  "r    ji        •    j_ 

variation  m  the  application  ot  the  inter- 
maxillary force  and  is  not  intended  to  illus- 
trate a  practical  apparatus  for  this  Type 
of  malocclusion.  It  is  frequently  desirable 
to  exert  a  distal  intermaxillary  force  upon 
the  buccal  teeth  or  upon  a  single  molar, 
without  exerting  any  distal  force  upon  the 
cuspids  or  any  of  the  front  teeth.  This  is 
accomplished  with  the  span  intermaxillary  hook,  which  is  easily  made  by  soldering 
two  short  open  tubes  to  a  No.  19  wire,  the  projecting  end  of  which  is  bent  to  form 
the  hook,  while  the  central  portion  "a"  is  bent  to  span  the  cuspid  attachment 
"b"  when  the  tubes  are  clasped  around  the  arch-bow.  In  the  construction,  the  wire 
is  first  bent  the  desired  form  and  flattened  with  a  file  at  the  points  where  the  open 
tubes  are  to  be  soldered.  This  is  one  of  the  most  practical  and  eftective  devices 
in  the  author's  practice  for  the  application  of  the  intermaxillary  force.  Instead 
of  the  sliding  tubes,  the  span  bar  may  be  lengthened  to  the  desired  distal  point  of 
engagement.  Through  the  medium  of  the  sliding  tubes  upon  the  arch-bow,  also, 
the  occipital  force  may  be  applied  directly  to  the  buccal  teeth  by  employing  the 
occipital  bow  C. 


CHAPTER   XXXV.     TYPE   B.     DIVISION  2.     CLASS  II. 


269 


In  all  cases  of  Type  B  of  this  Division  of  Class  II,  where  the  facial  outlines 
positively  indicate  a  protrusion  of  the  apical  zone  of  the  front  teeth,  the  regular 
bodily  retruding  apparatus  is  demanded.  This  is  illustrated  in  Fig.  193,  Chapter 
XXX VII,  where  will  be  found  the  technic  description  of  the  most  modern  method 
of  construction.  A  bodily  retrusive  movement  of  the  front  teeth  usually  requires 
more  force  and  greater  time  than  a  bodily  protrusive  movement,  because  it  is 
accomplished  wholly  by  resorption  of  the  walls  of  the  alveoli,  acted  upon  by  the 


force. 


Fi(,.  ISS. 


Fig.  188  was  made  from  the  plaster  casts  of  a  girl  thirteen  years  of  age.  The 
beginning  facial  cast  is  distinctively  characteristic  of  an  upper  bodily  protrusion; 
but  on  account  of  the  decided  labial  inclination  of  the  front  teeth,  it  was  hoped 
that  the  retruding  force  applied  at  the  gingival  margin  would  properly  retrude  the 
teeth  and  correct  the  facial  outlines.  It  was  found,  however,  after  a  partial  move- 
ment by  this  method,  that  the  protruded  apical  zone  was  brought  into  stronger 
evidence  than  at  first,  and  this  demanded  a  bodily  retrusive  movement,  which  was 
accomplished,  as  .shown  on  the  right,  with  an  apparatus  similar  to  that  shown  in 
Fig.  193,  Chapter  XXX VII.  The  three  stages  of  this  very  interesting  case  are 
fully  described  and  illustrated  in  Chapter  XXI. 


CHAPTER   XXXVI 

Type  C,  Division  2,  Class  II 

UPPER  CORONAL  PROTRUSION  WITH  APICAL  RETRUSION 

From  causes  not  always  possible  to  discover,  protrusions  of  the  crowns  of 
the  upper  front  teeth  are  accompanied  with  an  easily  recognized  retrusion  of  the 
apical  zone.  As  diseases  of  the  naso-maxillary  sinuses,  caused  from  adenoids,  may 
arise  in  every  physical  character,  inhibiting  the  development  of  the  maxilla,  it 
would  seem  that  this  somewhat  rare  type  illustrated  in  Fig.  189,  is  a  fair  sample  of 
the  effect  of  this  local  cause  upon  a  case  of  inherited  upper  coronal  protrusion. 

Fig.  189. 


The  labial  inclination  of  the  upper  front  teeth,  with  retruded  incisive  fossae, 
will  tend  to  protrude  the  coronal  zone  and  retrude  the  apical  zone,  thus  deepening 
the  naso-labial  depressions,  and  often  retruding  the  entire  lower  portion  of  the  nose 
in  relation  to  esthetic  facial  outlines.  Of  course  there  is  every  degree  of  dento- 
facial  disharmony  with  the  labial  teeth  in  this  same  inclination,  from  decided 

270 


CHAPTER  XXXVI.     TYPE  C.    DIVISION  2.    CLASS  II. 


271 


protrusions  of  the  coronal  zone  with  the  apical  normal,  to  decided  retrusions  of  the 
apical  zone  with  coronal  normal. 

It  will  be  seen  that  the  upper  buccal  teeth  are  in  full  mesial  malinterdigitation. 
In  other  words,  they  bite  fully  the  width  of  a  cusp  in  front  of  a  normal  occlusion. 
When  this  case  presented,  the  first  premolars  had  been  extracted,  and  an  attempt 
had  been  made  to  correct  the  protrusion.  Before  this,  it  was  said  that  the  teeth 
were  much  more  protruded  with  more  decided  labial  inclination,  and  this  must 
have  enhanced  the  retruded  effect  at  the  upper  part  of  the  lip.    This  retruded 

Fig.  190. 


effect  was  quite  apparent,  as  can  be  seen  by  the  profile  model  on  the  left.  Even  the 
end  of  the  nose,  compared  to  the  finished  case,  is  seen  to  have  been  improved 
in  its  outlines  in  the  labial  movement  of  the  roots  and  incisive  process. 

The  deepening  of  the  naso-labial  lines  at  the  points  where  they  join  the  wings 
of  the  nose,  which  is  apparently  caused  by  the  retruded  framework  supporting  the 
lower  end  of  the  nose,  is  enhanced  by  the  protrusion  of  the  coronal  zone,  and  this 
produces  a  peculiar  facial  expression  that  at  once  indicates  the  character  of  the 
dental  malposition.  It  is  an  expression  that  is  common  in  protrusions,  of  the  labial 
teeth  which  arise  from  thumb-sucking. 

Fig.  190  represents  one  of  the  regular  forms  of  contour  apparatus  used  for  the 
bodily  labial  movement  of  the  upper  front  teeth,  and  is  especially  designed  for  all 
cases  which  demand  a  protrusive  movement  of  the  upper  apical  zone  and  a  re- 


272  PART   VI.     DF.NTO-FACIAL   MALOCCLUSIONS 

trusivc  movement  of  the  coronal  zone.  In  fact,  the  two  forces  can  always  be  so 
adjusted  that  the  relative  degree  of  either  movement  is  completely  under  the  con- 
trol of  the  operator. 

Tlu"  mechanical  principles  which  underlie  the  method  of  applying  force  for 
the  movement  of  the  roots  of  teeth  are  fully  explained  under  "Bodily  Movement," 
Chapter  XIV.  When  this  method  was  first  published  in  1893,  the  author  named  it 
the  "Contour  Apparatus"  merely  for  convenience  and  because  it  was  the  first 
method  ever  invented  that  made  it  really  possible  to  practically  contour  the  dento- 
facial  area. 

This  method  of  applying  force  will  never  be  understood  or  appreciated  by 
any  one  who  is  not  willing,  or  is  incapable  of  skillfully  constructing,  fitting,  and 
placing  the  proper  appliances  for  the  correct  application  of  this  peculiar  form  of 
applied  force.  When  the  preliminary  work  is  accomplished  as  it  should  be,  there  is 
no  extensive  apparatus  that  will  give  so  little  trouble  or  annoyance  to  the  patient 
or  operator,  or  one  over  which  the  operator  has  more  perfect  control  of  the  move- 
ments of  the  teeth,  and  none  that  will  give  so  much  satisfaction  in  the  final  result. 
This  applies  particularly  t(.)  the  labial  movements  of  the  upper  front  teeth  in  Class 
III,  where  a  full  description  will  be  found  relative  to  the  details  of  constructing  and 
fitting  the  protruding  contour  apparatus  for  pronounced  cases  of  upper  retrusion. 

This  apparatus  dift'ers  from  that  in  Class  III  only  in  the  degree  of  its  possibil- 
ities of  movement.  In  all  cases  where  a  maximimi  power  is  not  demanded,  as  in 
extensive  movements  of  the  roots  for  the  older  class  of  patients,  the  entire  apparatus 
should  be  reduced  in  the  size  and  heft  of  its  parts  to  meet  the  requirements  and 
avoid  bulkiness.     See  Chapter  XX. 

The  reciprocal  action  of  the  two  required  forces  will  nullify  each  other  at 
the  anchorage  in  proportion  to  the  weaker  power,  and  this  is  true  of  all  reciprocal 
forces  acting  upon  a  given  point ;  therefore,  the  resultant  should  be  noted  as  to  the 
influence  it  exerts  upon  the  anchorage  teeth,  and  the  need  of  reinforcing  their 
stability  against  the  mesial  or  distal  movement  that  may  be  produced. 

For  instance,  in  the  irregularity  shown  by  the  drawings,  the  greater  power 
will  be  required  for  the  lingual  movement  of  the  crowns;  consequently,  the  excess 
will  tend  to  move  the  anchorage  teeth  mesially.  It  will  be  noticed  that  the  buccal 
teeth  of  the  drawing  demand  this  mesial  movement  about  one-quarter  the  width  of 
a  premolar  to  correct  their  interdigitating  occlusion;  therefore,  no  more  than  a 
two-band  stationary  anchorage  is  indicated.  But  if  the  cusps  of  the  upper  buccal 
teeth  were  in  full  mesial  interdigitation,  a  three-band  stationary  anchorage  would 
be  demanded  if  possible,  and  if  not,  the  occipital  or  intermaxillary  auxiliary  would 
be  indicated  to  prevent  a  mesial  movement  of  the  anchor  teeth. 

In  cases  where  the  apical  zone  of  the  front  teeth  is  Ijut  slightly  retruded,  the  force 
of  a  single  retruding  arch-bow,  applied  at  the  ineisal  zone,  will  usually  be  sufficient 
to  tip  the  roots  forward  the  required  distance  in  the  retrusive  movement  of  the 
crowns,  the  gingivo-lingual  borders  of  the  alveolar  process  acting  as  a  fulcrum. 


CHAPTER   XXXVI.     TYPE  C.     /^/IV.SYO.V   2.     CLASS  II.  273 

In  the  apparatus  shown  in  Fig.  190,  the  upper  or  "power  arch-bow"  No.  16, 
will  act  more  as  a  fulcrum,  and  the  lower,  or  "fulcrum  arch-bow"  No.  20  or  22, 
will  be  the  moving  power,  though  considerable  force  will  be  exerted  upon  the  power 
arch-bow. 

Fitting  the  Protruding  Contour  Apparatus 

In  the  fitting  and  assembling  of  this  apparatus,  the  power  arch-bow,  being 
very  rigid,  should  be  perfectly  bent  so  as  to  lie  evenly  in  its  respective  attachments 
without  the  slightest  spring  when  in  position.  In  the  final  placing  of  the  apparatus 
shown  in  Fig.  190,  first  cement  the  anchorage  upon  one  side,  and  place  the  end  of 
the  power  arch-bow  in  the  buccal  tube.  When  the  cement  is  placed  in  the  bands 
of  the  other  anchorage,  slip  its  tube  on  to  the  free  end  of  the  arch-bow  before  carry- 
ing the  anchorage  to  place  upon  the  teeth.  Then  the  labial  bands  are  placed  one 
at  a  time,  the  gingival  hooks  lapping  on  to  the  arch-bow.  The  placing  of  the  ful- 
crum arch-bow  needs  no  direction.  In  the  more  modern  stationary  anchorages  for 
bodily  movements,  the  power  tube  upon  one  anchorage  is  an  open-tube,  which 
greatly  facilitates  assembling  and  disassembling  the  power  arch-bow,  that  at  times 
is  of  the  greatest  importance. 

In  the  progress  of  the  operation,  if  it  is  found  that  the  roots  are  being  protruded 
more  than  they  should  be  in  proportion  to  the  position  of  the  crowns,  the  power 
bow  nuts  at  the  mesial  ends  of  the  anchorage  tubes  should  be  unscrewed,  and 
this  will  allow  the  roots  to  move  back.  It  will  be  seen  with  this  combination,  that 
the  operator  has  full  control  over  the  individual  movements  of  the  roots  and  the 
crowns  of  the  incisors. 


CHAPTER   XXXVII 

Type  D,  Division  2,  Class  II 

UPPER  APICAL   PROTRUSION 

Irregularities  of  this  Type  are  far  more  rare  than  their  opposites,  Type  C, 
probably  because  they  seem  to  be  unassociated  with  any  condition  that  may  have 
resulted  from  a  local  cause.  In  their  pronounced  forms,  they  are  characterized 
by  a  decided  prominence  or  bulginess  along  the  upper  part  of  the  upper  lip  and  base 
of  the  nose,  completely  obliterating  the  naso-labial  lines,  while  the  lower  part 
of  the  lip  is  not  protruded.     In  all  of  these  cases,  the  inherited  protruded  and  en- 

FlG.   1(11. 


larged  maxilla  is  often  quite  apparent.  If  the  sizes  of  the  upper  teeth  are  out  of 
proportion  to  the  large  maxilla,  as  Dr.  Cryer  has  proven  possible,  they  would 
undoubtedly  assume  a  lingual  inclination. 

In  these  cases  the  lips  close  with  difficulty,  and  rarely  with  repose,  and  when 
the  patient  is  talking  or  laughing,  they  often  rise  to  an  unpleasant  exposure  of, 
not  only  the  entire  crowns,  but  also  the  gums  above;  this  produces  at  times  an 
exceedingly  displeasing  expression. 

27-4 


CHAPTER  XXXVII.    TYPE  D.    DIVISION  2.    CLASS  II. 


275 


The  beginning  facial  and  dental  casts  shown  in  Figs.  191  and  192  will  serve  to 
illustrate  this  Type.  They  were  both  eighteen  years  of  age  at  the  commencement 
of  the  operations.  It  will  be  seen  that  the  apical  zones  were  greatly  protruded,  as 
shown  by  the  facial  casts  before  treatment.  The  incisal  edges  of  the  centrals  in 
these  cases,  as  is  common  with  this  malposition,  hugged  the  lower  incisors  near 
their  gingival  margins.  As  in  all  cases  of  this  Type,  the  occipital  force  is  an  impor- 
tant auxiliary',  particularly  because  of  its  intruding  direction. 

The  photograph  on  the  right  of  Fig.  191  was  taken  about  ten  years  after  the 
operation  was  completed.     Note  the  perfect  pose  of  the  upper  lip  in  the  finished 

Fig.  192. 


illustrations,  with  the  decided  protrusion  of  the  upper  apical  zone  and  flare  of  the 
nostrils  entirely  removed.  This  was  accomplished  by  the  extraction  of  the  fii-st 
upper  premolars,  followed  with  a  bodily  lingual  movement  of  the  roots  of  the  front 
teeth,  and  a  slight  labial  movement  of  the  occlusal  zone  of  the  incisors. 

Fig.  193  illustrates  the  common  contour  retruding  apparatus.  In  marked 
cases  of  Types  B  and  D  of  this  class  the  first  premolars  should  be  extracted, 
because  every  opportunity  should  be  given  for  the  retrusive  movement  of  the  roots 
and  alveolar  ridge. 

The  anchorages  for  all  apparatus  requiring  considerable  force  are  now  of 
the  two  or  three-band  stationary  type  with  power  applied  from  root-wise  attach- 
ments, the  construction  of  which  is  fully  described  in  Chapter  XV.  The  power 
arch-bow  is  No.  16  extra  hard  nickel  silver.    The  lower,  or  fulcrum  arch-bow  is  No.  17. 


276 


FART    VI.     DEN  TO-FACIAL   MALOCCLUSIONS 


The  latter,  which  now  acts  as  a  static  fulcrum,  necessarily  exerts  a  push  force, 
conseciuently  it  should  be  nearly  c^r  cjuitc  as  rigid  as  the  power  arch-bow  in  order  to 
prevent  the  retrusive  force  from  tipping  the  crowns  lingually.  As  the  retrusive 
movement  progresses,  the  nuts  at  the  mesial  ends  of  the  fulcrum  tubes  should  be 
turned  according  to  the  demands  for  keeping  the  front  teeth  in  a  noi-mal  inclina- 
tion. For  instance,  in  Type  B  of  this  Division,  where  a  general  retrusive  movement 
of  the  front  teeth  is  demanded,  the  fulcrum  nuts  are  occasionally  unscrewed  to 
allow  the  crowns  to  move  back  with  the  roots.    Again,  if  the  protrusion  pertains 

Fig.  hi:?. 


L 


^ 


a    b 


to  the  apical  zone  alone,  with  the  crowns  lingually  inclined,  as  in  the  present  Type, 
the  fulcrum  bow  may  need  to  act  as  a  protrusive  force  to  place  the  incisal  ends  in 
proper  relation  to  the  lower  teeth,  while  at  the  same  time,  the  power  bow  is  retrud- 
ing  the  roots.  In  all  cases  of  bodily  movements,  the  power  nuts  should  be  given 
two-quarter  turns  three  times  a  week. 

The  labial  bands  are  made  of  wide  No.  .0038"  banding  material,  and  when 
soldered  they  are  placed  on  the  teeth  to  outline  and  trim  the  fronts  to  a  width  of 
about  l/lO  of  an  inch.  Upon  removal  of  the  bands,  flow  over  their  labial  surfaces 
No.  16  gold  solder  to  strengthen  and  give  artistic  effect,  as  fully  described  in 
Chapter  XX  in  the  construction  of  the  "Midget  Apparatus."  All  the  bands  are 
now  fitted  perfectly  to  the  teeth  in  the  exact  position  they  will  occupy  in  the  finished 
apparatus.     Note  that  the  occlusal  borders  of  the  incisor  bands  are  even  with  the 


CHAPTER  XXXVII.     TYPE  D.     DIVISION  2.     CLASS  II.  277 

upper  border  of  the  fulcrum  bow,  and  that  the  lower  border  of  this  bow  is  about  l/lO 
of  an  inch  above  the  cutting  edges.  This  will  indicate  the  position  the  occlusal 
borders  of  the  bands  should  take  upon  the  lateral  incisors,  which  are  usually  shorter 
than  the  centrals.  The  occlusal  and  gingival  borders  of  the  central  bands  should 
be  in  line  with  the  bands  of  the  laterals.  When  the  bands  are  properly  fitted  to  the 
teeth,  a  plaster  impression  is  taken;  the  bands  are  then  carefully  removed  from  the 
teeth  and  fitted  into  their  respective  positions  in  the  impression,  which  is  filled 
with  strong  investment  plaster. 

The  root-wise  attachments  should  be  shaped  so  as  to  withstand  the  force, 
protect  the  gums,  and  still  not  be  bulky.  In  the  ekrlier  construction  of  this  appara- 
tus, the  power  was  applied  above  the  gingival  margins  to  obtain  the  greatest 
possible  mechanical  advantage.  It  has  been  found  in  recent  years  that  this  is 
rarely  necessary  with  a  proper  management  of  the  two  forces.  In  the  present 
apparatus,  the  power  is  applied  just  below  the  gingival  borders  directly  upon  the 
surface  of  the  crowns  and  along  a  line  that  is  even  with  the  highest  gingival  points 
upon  the  lateral  incisors.  This  method  has  the  very  great  advantage  of  reducing 
bulkiness  and  prominence  of  the  bow  and  attachments,  and  particularly  the  ease 
of  construction. 

The  root-wise  attachments  for  the  front  teeth  are  now  made  of  No.  16  hook 
wire.  This  is  about  eciual  in  weight  to  No.  17  (.045")  rolled  to  a  ribbon  thickness 
of  .013". 

In  Fig.  193  is  shown  at  "a"  and  "b"  a  front  and  edge  view  of  the  hook  wire, 
which  after  annealing  is  bent  sharply  at  right  angles  "c"  and  curved  to  form  the 
fulcrum  bow  attachment  "d."  This  is  thinned  at  the  end  to  form  a  smooth  finish 
where  it  partly  laps  around  the  bow.  In  determining  the  point  at  which  the  wire 
should  be  cut  off  for  the  power  attachment,  remember  that  the  fulcrum  attach- 
ments start  from  the  occlusal  borders  of  the  bands,  therefore,  place  it  upon  the 
model  and  measure  to  the  gingival  border  of  one  of  the  lateral  incisors.  The 
root-wise  pieces  are  cut  the  same  length,  and  the  gingival  ends  are  grooved 
slightly  for  the  power  attachments.  These  are  short  sections  of  thin  wall  No.  16 
open-tubing,  which  are  soldered  in  place  with  No.  IG  gold  solder  by  holding 
them  in  the  solder  pher  ("e").  The  pieces  are  now  ready  to  be  fitted  and 
soldered  to  the  bands  on  the  model  ("f").  The  gold  solder  that  was  previously 
flowed  over  the  front  of  the  bands  is  usually  sufficient  for  this  purpose.  In  this 
act,  the  attachment  is  held  firmly  in  place  with  a  steel  poker  dipped  in  plumbago; 
or  the  band  may  be  removed  from  the  model  and  the  parts  held  in  place  in  the 
solder  plier. 

For  young  patients  with  less  pronounced  bodily  protrusions,  the  arch-bows, 
bands,  and  attachments  may  be  considerably  reduced  in  size.  This  is  especially 
true  if  the  appliances  are  made  of  platinum-gold. 

In  assembling  the  apparatus  preparatory  to  cementing  it.  the  arch-bows  should 
be  bent  so  that  when  in  place  they  will  lie  evenly  in  their  attachments  without  the 


278  PART   VI.    DENTO-FACIAL  MALOCCLUSIONS 

spring  of  the  material.  One  of  the  most  important  and  convenient  moves  in  the 
construction  of  all  apparatus  which  require  heavy  arch-bows,  is  the  employment 
of  open  anchorage  tubes  on  the  right  or  the  left  anchorage,  fully  described  and 
illustrated  in  other  chapters.  This  is  particularly  desirable  with  the  present  appa- 
ratus, as  it  is  quite  difificult  to  force  the  power  and  fulcrum  bows  into  closed  anchor- 
age tubes  after  the  bands  are  cemented  on  the  teeth.  With  the  open  anchorage 
tubes,  the  arch-bows  are  easily  assembled  by  first  placing  one  end  of  the  power 
bow  in  its  closed  tube  and  carrying  the  other  end  over  and  fitting  it  along  into  the 
front  attachments,  and  finally  into  its  open -tube  on  the  other  anchorage;  the 
fulcrum  bow  is  fitted  in  the  same  manner.  Furthermore,  it  is  frequently  necessary 
to  give  final  slight  bends  to  the  bows  here  and  there  so  they  will  lie  evenly  without 
tension  in  the  several  attachments.  This  can  be  easily  accomplished  if  the  bows 
can  be  readily  removed  and  replaced  in  the  final  necessary  fatting. 

This  lengthy  description  with  its  necessary  detail  may  lead  many  to  imagine 
that  the  construction  of  this  apparatus  is  fraught  with  unusual  difficulty,  whereas, 
it  is  no  more  difficult  than  other  appliances  after  one  gets  into  the  run  of  the  several 
requirements,  and  is  skilled  in  the  technic,  as  all  orthodontists  should  be  who 
hope  to  successfully  accomplish  the  important  operations  in  this  specialty  of 
dentistry. 


CONCOMITANT  CHARACTERS  OF  CLASS  II 


CHAPTER  XXXVIII 

RETRUSION   OF  THE  MANDIBLE  AND   LOWER  DENTURE 

Fig.  194.  One  of  the  facial  characteristics  which  is  common 

to  pronounced  malocclusions  of  Class  II,  and  one, 
moreover,  which  greatly  complicates  the  diagnosis 
and  treatment,  is  a  retruded  position  of  the  chin 
and  lower  lip,  which  means,  of  course,  a  retruded 
position  of  the  mandible  and  lower  denture,  just  as 
if  the  body  of  the  mandible  and  its  contained  teeth 
had  been  forced  back  of  their  normal  position,  as 
diagrammatically  shown  in  Fig.  194,  and  the  be- 
ginning facial  outlines  of  cases  in  practice. 

Cases  of  this  character  differ  quite  decidedly  in 
profile  outlines  and  treatment  from  the  other  Types 
of  Division  1,  in  which  the  lower  teeth  alone  are 
retruded,  while  the  chin  and  the  body  of  the  lower 
jaw  are  in  normal  relations — though  in  both  charac- 
ters the  same  occlusion  of  the  teeth  may  be  exactly 
alike.  Moreover,  retrusions  of  the  mandible,  in 
the  author's  practice,  have  been  found  quite  as 
frequent  in  connection  with  upper  protrusions;  and 
consequently  this  Type  may  be  considered  as  be- 
longing properly  to  Divisions  1  and  2. 

Inasmuch  as  the  relative  position  of  the  chin 
varies  in  different  individuals  from  decided  prognathisms  to  decided  retru- 
sions, and  as  some  form  of  this  malrelation  may  obtain  in  connection  with  any 
other  character  of  irregularity,  we  therefore  find  every  gradation  of  this  bodily 
retrusion  of  the  lower  jaw  and  teeth  in  connection  with  every  gradation  of 
protrusion  of  the  upper  teeth. 

Diagnosis  and  General  Treatment 

In  all  cases  of  marked  antero-posterior  malrelations  of  the  dentures,  one 
should  always  strive  to  prevent  being  deceived  by  a  facial  effect.  Where  the  man- 
dible and  contained  teeth  are  decidedly  retruded  in  their  esthetic  relations,  the 

279 


280 


PAKT    17.     DEMO-I'ACIAL   MALUCCLL\SIU.\S 


effect  is  usually  that  of  an  upper  protrusion,  even  when  the  u]:)per  lip  is  nearly  or 
quite  in  normal  relation  to  the  remaining  features. 

For  the  perfect  correction  of  occlusion  and  facial  outlines,  cases  of  this  Type 
really  demand — if  it  were  possible — the  operation  known  as  "jumping  the  bite," 
which  was  introduced  by  Dr.  Norman  Kingsley  in  1882.  This  consists  in  attaching 
an  apparatus  to  the  teeth,  which  is  intended  to  force  the  mandible  forward  the  de- 
sired distance,  and  to  hold  it  there  until  nature  has  so  changed  the  tempero-maxil- 
lary  articulation  as  to  render  it  impossible  for  the  jaw  to  ever  go  back  to  its  original 
position. 

Fig.  105 


In  the  Dental  Review  of  May  and  July  1894,  will  be  found  a  complete  resume 
of  the  hterature  of  "jumping  the  bite,"  with  the  author's  description  of  the  diffi- 
culties which  would  need  to  be  overcome  in  a  successful  operation  of  this  character; 
the  whole  is  intended  to  show  the  improbability  of  permanent  success.  After  many 
long  continued  trials  to  "jump  the  bite"  for  patients  younger  than  twelve,  all  of 
which  ultimately  were  failures,  and  as  the  author  has  never  seen  from  the  hands  of 
others  a  single  well  authenticated  case  of  permanent  correction  by  this  method, 
he  cannot  advise  anyone  to  undertake  it. 

On  the  other  hand,  while  it  may  be  possible  with  this  character  of  malocclusion 
to  bring  the  teeth  to  a  normal  occlusion  by  an  interstitial  movement,  with  the 
intermaxillary  force,  this  operation  in  all  marked  cases  should  not  be  attempted, 


CHAPTER   XXXVIII.     CONCOMITANT  CHARACTERS.     CLASS  II.  281 

because  the  lower  lip  would  be  forced  abnormally  forward  by  the  required  extreme 
labial  movement  of  the  lower  teeth,  with  the  production  of  a  receding  chin  effect. 
And  in  those  cases  where  the  upper  teeth  are  considerably  protruded,  this  operation 
would  in  all  probability  result  in  that  most  unhappy  deformity  characterized  by  a 
bimaxillary  protrusion. 

In  all  cases,  therefore,  of  retruded  lower  teeth  and  mandible,  accompanied  with 
protrusion  of  the  upper,  the  extraction  of  upper  teeth  is  always  indicated  to  produce 
as  in  all  pronounced  upper  protrusions,  the  extensive  lingual  movement  of  the 
upper  labial  teeth  to  harmonize  the  facial  outlines. 

While  a  lingual  movement  of  the  upper  labial  teeth,  even  to  the  full  width 
of  a  premolar,  will  not  produce  the  same  perfection  of  facial  outlines  obtainable  in 
other  cases  of  this  Class  on  account  of  the  retruded  position  of  the  lower  teeth  and 
chin,  still  the  improvement  is  always  an  exceedingly  pleasing  one,  and  one,  more- 
over, which  is  far  more  liable  to  retain  its  position  than  the  operation  which  re- 
quires a  movement  of  all  the  teeth.  In  Fig.  195,  is  shown  the  results  of  this 
method  of  correction  in  two  cases  of  this  Type.  Two  cases  of  this  Type  are  also 
illustrated  under  Fig.  170,  Chapter  XXX. 

It  is  important  in  the  diagnosis  of  these  cases  to  determine  whether  an  inclina- 
tion lingual  movement  of  the  front  is  demianded,  or  a  bodily  lingvial  movement. 
The  diagnosis  and  treatment  of  these  two  distinct  Types  are  the  same  as  Types  A 
and  B  of  Division  2  of  this  Class. 

It  should  never  be  forgotten  that  one  of  the  indispensable  conditions  of  per- 
manent retention  is  an  accurate  interdigitation  of  buccal  cusps.  In  nearly  all 
cases  of  this  Type  with  a  full  complement  of  teeth,  the  upper  buccal  cusps  will  be 
found  in  mesial  malinterdigitation,  a  condition  which  is  very  important  to  retain. 
If  however,  after  producing  normal  width  relations  of  the  arches,  it  is  found  that 
the  general  mesio-distal  and  bucco-lingual  relations  are  imperfect  in  this  particular 
they  should  be  intelligently  shifted  with  the  intermaxillary  elastics.  The  depth  of 
the  labio-mental  depression  will  at  once  indicate  whether  a  forward  movement  of 
the  teeth  is  admissible.  Usually,  in  this  Type,  such  a  movemeni  is  not  advisable,  in 
which  case  the  lower  bviccal  teeth  should  be  firmly  united  in  stationary  anchorages 
and  so  joined  to  the  front  teeth  as  to  prevent  a  mesial  movement  from  the  inter- 
maxillary force.  On  the  other  hand,  the  force  should  be  applied  to  the  upper  teeth 
at  points  which  produce  the  easiest  movement  with  the  least  display  of  power. 

In  this  connection,  it  may  be  stated  again  that  a  lingual  movement  of  the 
upper  labial  teeth,  even  slightly  beyond  the  normal  relation,  will  produce  a  far 
more  pleasing  facial  effect  by  placing  the  upper  lip  in  closer  harmony  with  the  lower, 
than  will  result  from  a  protrusion  of  the  lower  lip  at  the  expense  of  obliterating  the 
labio-mental  curve,  to  say  nothing  of  the  possibilities  of  producing  a  receding  chin 
eft'ect.  It  woiild  be  well  to  remember  this  in  cases  where  the  upper  is  but  slightly 
protruded,  or  normal,  in  connection  with  a  decided  bodily  retruded  position  of  the 
mandible  and  teeth. 


282  PART   17.    DENTO-FACIAL  MALOCCLUSIONS 

It  will  have  been  observed  that  in  connection  with  this  Type,  the  rule  for 
extraction  is  the  same  as  in  Division  2.  It  is  needless  to  say,  also,  that  every 
device  should  be  taken  advantage  of  to  avoid  moving  the  upper  anchorage  teeth 
forward;  and  consequently,  the  principal  movement  may  demand  the  intermaxil- 
lary and  occipital  force  alone,  with  an  employment  of  the  stationary  anchorages 
mainly  for  the  purpose  of  taking  up  the  slack  of  the  retruding  bow  and  to  retain 
the  positions  gained. 

In  this  operation,  the  intermaxillary  force  will  be  a  valuable  and  effective 
adjunct,  if  the  tendencies  of  its  movement  are  properly  controlled,  and  especially 
in  cases  that  ai^e  complicated  with  a  close-bite  malocclusion,  because  of  the  extru- 
sive force  which  the  elastics  will  exert  upon  the  lower  buccal  teeth  whenever  the 
mouth  is  opened. 


CHAPTER  XXXIX 

CLOSE-BITE   MALOCCLUSION 

One  of  the  most  common  complications  of  Class  II  is  a  Close-bite  Malocclu- 
sion, the  lower  incisors,  upon  closure  of  the  jaws,  frequently  striking  into  the  gums 
far  back  of  the  uppers  along  the  lingvio-incisal  alveolar  ridge.  This  renders  a  lin- 
gual movement  of  the  upper  incisors  impossible  until  provision  is  first  made  for 
permanently  opening  the  bite  by  methods  which  are  here  fully  explained. 

In  the  early  days  of  regulating  teeth,  this  character  of  malocclusion  was  con- 
sidered one  of  the  most  difficult,  if  not  impossible,  to  con-ect,  because  every  attempt 
to  retrude  the  protruding  front  teeth  would  cause  the  lower  incisors  to  strike  deeper 
into  the  gums. 

The  first  method  which  obviated  this  difficulty,  and  enabled  the  author  to  per- 
form what  was  considered  at  that  time  quite  a  wonderful  correction  of  a  pronounced 
upper  protrusion,  was  by  obUging  the  unhappy  patient,  during  the  time  of  the 
operation,  to  masticate  food  with  the  lower  incisors  striking  an  extension  of  a  rubber 
plate  which  was  worn  in  the  roof  of  the  mouth.  This  method  was  later  presented 
with  a  full  illustration  of  a  case  in  practice  before  the  Illinois  State  Dental  Society 
in  1892.  It  was  believed  to  be  at  that  time  such  an  advance  step  in  orthodontia, 
its  publication  in  the  Dental  Review  was  copied  by  a  number  of  textbooks,  which 
unfortunately  continued  to  publish  it  long  after  this  very  crude  method  had 
become  obsolete. 

This  incident  is  mentioned  here  to  show  how  very  few  years  have  elapsed  since 

rubber  plates  were  considered  one  of  the  principal  means  in  the  regulation  of  teeth. 

Fig.  19<).  A  number  of  years  later,  the  author 

introduced  another  far  more  efficient  and 
less  troublesome  method  which  is  illus- 
trated in  Fig.  196.  To  this  was  added  the 
now  indispensable  shell  crowns  instead 
of  bands  on  the  first  molars,  which  at 
once  opens  the  bite  to  the  desired  extent 
and  permits  a  rapid  extrusive  movement 
of  the  premolars  to  the  new  occlusal 
plane,  through  the  action  of  the  spring 
arch-bow.  The  second  molar  being  the  yotingest  tooth  and  often  not  fully  erupted, 
will  continue  its  growth  to  the  new  functional  occlusal  plane.  Furthermore,  the 
reaction  of  the  spring  bow  in  front  exerts  an  intrusive  force  upon  the  incisors, 
which  aids  in  correcting  their  supra-occlusal  position,  and  provides  room  for  the 

283 


284 


PART    VI.     DENTO-FACIAL   MALOCCLUSIONS 


desired  retrudinj;  mox'enient  (jf  the  upper  front  teeth  and  for  the  deiito-facial 
and  occhisal  correction  of  the  entire  denture;  the  whole  operation  being  carried  on 
at  the  same  time  and  with  very  httle  suffering  to  the  patient. 

The  first  molars,  Ijeing  the  oldest  and  strongest,  and  consequently  the  most 
stable  teeth  in  the  mouth,  are  admirably  adapted  for  the  crowns  to  sustain  the 
forces  of  mastication  for  the  very  few  months  which  are  required  to  establish  the 
full  masticating  position  of  the  other  teetli.  It  would  seem  that  the  sudden  neces- 
sity of  commencing  and  continuing  the  entire  mastication  upon  these  crowns  alone 

Fig.  197. 


would  give  considerable  annoyance  and  perhaps  pain  to  patients,  but  one  is  surprised 
to  hear  so  little  complaint,  and  to  see  how  quickly  they  cease  to  pay  any  attention 
to  this  part  of  the  operation. 

Fig.  197  illustrates  the  most  modern  construction  of  this  apparatus.  The 
hook  and  tube  attachments  on  the  bands  and  crowns  should  be  placed  so  that  the 
resilient  force  of  the  bow  No.  22  or  23  (.025"  or  .0225")  will  exert  a  strong  extru- 
sive force  upon  the  premolars  and  an  intrusive  force  upon  the  incisors.  Instead  of 
seamless  rovind  tubes  on  the  molar  crowns,  U-tubes,  open  at  the  top,  will  enable  an 
easy  assembling  and  removal  of  the  bow. 

The  shell  crowns  for  tlie  purposes  of  this  work  are  easily  made  as  follows: 


Take  measurements  using  wide  No.   .005 


banding  material. 


After  soldering, 


CHAPTER  XXXIX.    CONCOMITANT  CHARACTERS.     CLASS  II.  285 

contour  and  fit  as  for  ordinary  bands,  except  that  the  occlusal  edges  should  stand 
slightly  above  the  occluding  surfaces  when  fitted  to  place.  Now  remove  the  bands 
and  slit  their  edges  so  that  they  can  be  bent  over  on  the  occluding  borders  with 
the  wood-plugger.  When  this  is  accomplished,  take  bite  impressions  with  modeling- 
compound  or  wax,  using  only  sufficient  material  to  partly  cover  the  crowns  and 
the  occluding  tooth  or  teeth.  Remove  the  bands  and  place  accurately  in  the  im- 
pressions and  fill  with  investing  plaster,  then  set  them  up  in  an  articulator. 

Swage  the  occluding  caps  of  very  thin  nickel  silver  plate  No.  35  (.006")  and 
fit  them  to  the  bands  so  that  their  edges  overlap  the  occlusal  zone.  Accuracy  of 
occlusion  is  not  essential  at  this  stage.  When  these  caps  are  lightly  soldered  along 
their  borders  to  the  bands,  and  again  placed  on  the  teeth,  the  patient  will  be  able 
to  indent  them  with  the  occluding  teeth  and  thus  produce  a  perfect  occluding 
surface. 

Another  advantage  of  thin  caps  is:  when  both  crowns  are  placed  for  trial 
fitting,  slight  imperfections  in  the  occluding  surfaces  may  be  easily  corrected  by 
the  patient  in  closing  the  jaws. 

Fig.  198. 


Before  the  crowns  are  placed  on  the  teeth,  bore  holes  through  the  mesio-buccal 
occluding  sulci  for  an  exit  of  excess  cement,  and  particularly  for  the  insertion  of 
the  occluding  beak  of  the  crown-removing  plier,  Fig.  198.  In  finishing  the  bands, 
an  additional  amount  of  solder  may  be  fiowed  along  the  borders  of  the  caps  to 
even  the  surfaces. 

Later,  it  occasionally  becomes  necessary  to  thicken  the  occluding  surfaces 
by  soldering  on  another  cap  to  each  crown  so  as  to  open  the  bite  still  wider.  In 
removing  the  crowns  for  this  purpose,  and  in  finally  removing  them,  the  cement  is 
burred  out  of  the  holes  through  to  the  surface  of  the  enamel.  The  point  of  the 
occluding  beak  of  the  plier  is  placed  in  the  hole  resting  upon  the  crown  of  the  tooth. 
This  forms  a  solid  fulcrum  to  the  power  of  the  other  beak  placed  under  the  gingival 
edge  of  the  crown,  enabling  one  to  easily  lift  it  from  its  attachment,  with  no  wrench- 
ing force  upon  the  roots. 

When  the  teeth  have  become  permanently  established  in  their  new  occlusal 
positions,  the  crowns  can  then  be  removed  and  replaced  with  bands  bearing  hooks 
for  direct  intermaxillary  elastics  leading  to  the  opposing  stationary  anchorages 
for  an  extrusive  movement  of  these  first  molars  to  the  new  occlusal  po-sition.    Any 


286 


PART   VI.    DENTO-FACIAL  MALOCCLUSIONS 


Fig.  199. 


linguo-l)uccal  malpositions  of  occlusion  are  readily  corrected  through  a  proper  ad- 
justment of  the  elastics.  For  instance,  if  the  lower  molars  are  in  buccal  mal- 
position in  relation  to  the  upper,  the  elastics  are  attached  to  a 
buccal  hook  on  the  lower  molar  and  to  a  lingual  hook  on  the  upper. 
See  Fig.  199.  These  are  readily  adjusted  and  removed  by  the 
patient  at  mealtime.  The  ordinary  "election  rings"  are  usually 
too  large  for  direct  intermaxillary  force;  therefore,  in  adjustments, 
they  should  be  carried  forth  and  back,  which  doubles  their  force. 
The  crowns  may  at  times  be  dispensed  with  for  young  patients, 
with  the  expectation  of  commencing  the  extruding  movement  of 
the  lower  molars  with  the  intermaxillary  elastics  at  the  beginning  of  the  operation, 
as  shown  in  Fig.  200. 

Fig.  200. 


A  two-band  stationary  anchorage  is  attached  to  the  molars,  with  provisions 
for  the  attachment  of  elastics  and  for  the  bow  to  extrude  the  premolars,  etc.  This 
arrangement  is  particularly  applicable  for  the  correction  of  close-bite  malocclusions 
in  Division  2,  where  little  or  no  mesial  movement  of  the  buccal  teeth  is  desired. 
For  cases  in  Division  1 ,  single  bands  upon  the  first  and  second  molars,  with  short 
buccal  tubes  for  the  bow,  would  permit  a  mesial  and  extruding  movement.  The 
intermaxillary  elastics  passing  more  directly  from  one  jaw  to  the  other  are  calculated 
to  exert  a  direct  extruding  force  upon  both  the  lower  and  upper  buccal  teeth. 


CHAPTER  XXXIX.    CONCOMITANT  CHARACTERS.    CLASS   II.  287 

The  occipital  bow  A,  in  Fig.  78,  shown  in  position,  may  be  exchanged  for  occip- 
ital bow  C,  shown  on  the  right,  if  a  more  direct  retruding  force  upon  the  cuspids 
is  demanded. 

General  Bimaxillary  Infra-Occlusion 

A  more  rare  character  of  close-bite  malocclusion,  which  may  be  properly  termed 
bimaxillary  infra-occlusion,  has  occasionally  fallen  under  the  author's  observa- 
tion for  treatment.  Though  it  differs  quite  decidedly  from  the  typical  close-bite 
malocclusion,  it  is  placed  in  this  Class,  because  it  requires  similar  methods  of 
treatment. 

It  refers  to  cases  in  which  both  the  front  and  back  teeth  are  in  an  infra-occlusal 
position  in  relation  to  a  typical  dento-facial  occlusal  plane,  shown  by  the  fact  that 
the  occlusal  edges  of  the  front  teeth  are  in  a  marked  intrusive  position  in  relation 

FiG.201. 


to  a  reposeful  parting  of  the  lips,  and  also  by  the  fact  that  when  the  jaws  are  closed 
in  mastication  the  lips  in  contact  are  forced  forward  with  a  marked  redundancy  of 
lip  tissue.    See  Fig.  201. 

In  this  case,  the  difificulty  of  occluding  the  teeth,  with  the  production  of  a  painful 
disturbance  at  the  temporo-maxillary  articulation,  led  to  imperfect  mastication 
of  food,  which  was  accomplished  principally  with  the  incisors  alone.  On  the  left  is 
shown  the  profile  cast  with  the  teeth  in  masticating  occlusion.  It  is  unfortunate 
that  it  does  not  fully  express  the  facial  disfigurement  which  was  far  more  pronounced 
than  is  here  indicated. 

The  impression  for  the  facial  cast  on  the  right  was  also  taken  at  the  same 
time,  but  with  the  dentures  held  apart  with  modeling-compound  for  the  purpose 
of  showing  the  amount  of  extruding  movement  that  would  be  necessary  to  produce 


288 


PART    VI.     DENTO-FACIAL  MALOCCLUSIONS 


a  proper  facial  effect.  For  this  purpose,  the  modeHng-compound  was  placed  be- 
tween the  teeth  and  the  jaws  carefully  closed  to  the  desired  position,  at  which  point 
the  facial  impression  was  taken.  Then  the  modelinj);-compound  bite  was  removed 
from  the  mouth  and  the  dental  easts  were  placed  in  it  and  fixed  in  that  position  as 
shown  on  the  right,  from  which  the  illustration  above  was  made.  The  propor- 
tionate excess  of  lip  tissue  would  have  permitted  the  jaws  to  have  opened  still 
wider,  without  disturbing  the  ease  of  a  perfect  closure  of  the  lips. 

The  apparatus  which  was  first  attached  consisted  of  four  crowns  placed  upon 
the  first  molars.  This  opened  the  jaws  to  about  one-lialf  the  desired  extent,  to 
start  with.  The  premolars  and  labial  teeth  were  all  banded  with  attachments  to 
support  alignment  arch-bows  with  spurs  for  the  attachment  of  the  direct  inter- 
maxillary elastics,  so  as  to  extrude  all  of  these  teeth  with  a  uniform  movement, 
treating  the  case  in  this  particular  as  though  it  were  an  open-ljite  malocclusion. 
Provision  was  also  made  for  the  attachment  of  the  disto-mesial  intermaxillary 
elastics  for  the  purpose  of  closing  the  interproximate  spaces,  and  correcting  the 
occlusion  by  a  retruding  movement  of  the  upper  labial  teeth,  and  a  mesial  movement 
of  the  lower  buccal  teeth. 

Within  a  few  months,  all  of  the  intruded  buccal  teeth,  except  the  crowned 
molars,  were  observed  to  be  in  perfect  occlusion,  whereupon,  the  lower  crowns  were 
removed  and  an  added  layer  soldered  to  their  occlusal  surfaces.  These  being  re- 
placed, the  several  forces  were  continued  as  before  for  a  few  months,  with   the 

second  complete  closure  of  occlusal  planes; 
then  the  upper  crowns  were  treated  in  the 
same  manner,  etc.,  etc. 

In  this  way  the  teeth  were  gradually  moved 
to  the  desired  new  occlusal  plane,  which  was 
not  in  the  sense  of  pulling  them  oid  of  their 
sockets,  but  with  an  apparent  concomitant 
movement  of  the  surrounding  gum  and  al- 
veolar process.  It  was  at  this  point  in  the 
operation  that  the  casts  shown  in  Fig.  202 
were  made. 

The  regulating  apparatus  was  now  changed 
for  the  more  delicately  constructed  and 
less  unsightly  retaining  appliance.  (See  Fig. 
306,  Chapter  LIV. )  When  assured  that 
the  positions  of  the  extruded  buccal  teeth  were 
permanent,  the  crowns  were  removed  from 
the  first  molars  and  replaced  with  bands 
bearing  hooks  for  the  direct  application 
of  intermaxillary  elastics,  which  finally  extruded  these  teeth  to  the  new  plane 
of  occlusion  as  in  the  regular  cases  of  close-bite  malocclusion. 


Fig.  202. 


CHAPTER  XXXIX.    CONCOMITANT  CHARACTERS.    CLASS  II. 


289 


Fig.  203. 


Another  case  which  came  for  treatment  was  far  more  pronounced  than  any  case 
of  bimaxillary  infra-occlusion  that  has  fallen  under  the  author's  observation.    The 

relative  position  of  the  models  shown  in 
Fig.  203  were  photographed  while  articu- 
lated on  the  wax  bite  which  produced  the 
proper  facial  outlines.  In  other  words, 
the  jaws  required  to  be  opened  that  much 
to  produce  the  best  facial  efifect.  An 
appointment  was  then  made  with  the 
patient  for  the  facial  cast,  but  very  much 
to  the  author's  regret,  she  did  not  return 
for  it.  It  is  hoped  that  she  fell  into  the 
hands  of  some  orthodontist  who  will  fully  appreciate  the  condition,  and  pursue 
the  proper  treatment. 

When  the  jaws  were  closed  in  this  case,  the  mandible  carried  the  lower  labial 
teeth  in  front  of  the  upper,  on  the  same  principle  that  the  closure  of  the  jaws  of  an 
edentulous  mouth  will  carry  the  mandible  far  in  front  of  the  maxilla,  because  of  the 
relative  position  of  the  condyles. 


CLASS  III 

MESIAL   MALOCCLUSION   OF   LOWER   BUCCAL  TEETH 


DIVISION  1 
DIVISION  2 
DIVISION    3 

DIVISION    4: 


Table  of  Divisions 

BODILY   RETRUSION   OF   UPPER  DENTURE  AND   MAXILLA 

CONTRACTED   RETRUSION   OF  UPPER   DENTURE 

RETRUSION   OF   THE  UPPER  WITH   PROTRUSION   OF   LOWER 
DENTURE 

RETRUSION  OF  THE  UPPER  WITH  PROGNATHIC  MANDIBLE,  COM- 
MONLY ACCOMPANIED  WITH  OPEN-BITE  MALOCCLUSION 


CLASS  III 


CHAPTER  XL 

PRINCIPLES   OF   DIAGNOSIS,  CAUSES,  AND  TREATMENT 

Upon  entering  the  field  of  dento-facial  malocclusion  which  is  characterized  by 
upper  retrusions,  we  have  come  to  a  class  of  irregularities  whose  very  frecjuent 
cause,  though  often  that  of  heredity,  is  of  local  origin,  because  of  the  quite  prevalent 
adenoids,  rhinological  stenosis,  and  mouth-breathing,  which  follow  each  other  in 
sequence,  inhibiting  the  development  of  the  maxilla,  and  causing  conditions  which 
emphasize  the  abnormality.  Certain  cases  seem  to  be  wholly  due  to  the  above 
local  causes,  while  others  are  due  wholly  to  heredity,  and  others  again,  are  due 
partly  to  one  and  partly  to  the  other. 

The  correction  of  upper  retrusions  is  quite  as  important  and  as  frequently 
demanded  as  upper  protrusions.  While  there  will  be  found  quite  a  similarity  in  the 
facial  expressions  of  nearly  all  the  types  belonging  to  this  Class,  it  is  nevertheless 
true  that  they  present  a  vast  variety  of  dental  malrelations,  arising  as  they  do  from 
both  local  causes  and  heredity — separately  and  in  combination — and  frequently 
demand  the  highest  order  of  mechanical  skill,  ingenuity,  and  artistic  ability  to 
correct. 

This  Class  is  facially  characterized  by  a  retruded  position  of  the  entire  tipper 
lip  in  relation  to  the  rest  of  the  features,  with  an  abnormal  deepening  of  the  naso- 
labial lines,  and  occasionally  a  retruded  position  of  the  end  of  the  nose,  as  will  be 
seen  in  many  of  the  illustrations  presented. 

It  will  be  seen  that  this  Class,  therefore,  differs  from  the  other  two  Classes 
of  malocclusion  in  that  all  its  Divisions  and  types  are  stamped  with  the  one  charac- 
teristic and  peculiar  facial  expression,  however  much  they  may  differ  in  other 
particulars.  This  means  that  they  all  demand  bodily  labial  movement  of  the  upper 
front  teeth,  though  the  apparatus  for  this  movement  may  have  a  number  of  auxil- 
iaries for  the  correction  of  other  malpositions  belonging  to  the  case. 

In  pronounced  cases  of  upper  retrusion — as  pointed  out  in  the  chapter  on 
Diagnosis — the  first  mental  impression  upon  the  observer  is  that  it  is  due  to  a 
prognathic  mandible.  This  unfortunately  has  often  led  to  a  wrong  diagnosis, 
followed  with  attempts  to  correct  with  occipital  force  applied  to  the  chin. 

Fig.  204  shows  the  plaster  casts  before  and  after  treatment  of  a  young  man 
about  eighteen  years  of  age.  The  retruded  upper  was  caused  by  the  extraction 
of  badly  decayed  and  broken-down  upper  first  molars  during  childhood.     It  was 

291 


292  PART   VI.    DENTO-FACIAL  MALOCCLUSIONS 

diagnosed  as  a  prognalhic-  mandible  at  the  International  Congress  of  1900  at  Paris, 
and  the  patient  was  then  fitted  with  a  head-cap  and  chin-piece  which  he  studiously 
wore  at  all  permissible  hours  for  over  a  year  in  a  fruitless  endeavor  to  retrude  the 
mandible  and  lower  denture.     In  the  meantime  he  had  entered  an  Eastern  college 

Fig.  204. 


in  this  country,  and  was  refen-ed  to  the  atithor  by  a  New  York  dentist.  The  facial 
and  dental  casts  on  the  left  show  the  condition  at  that  time.  The  casts  on  the  right, 
made  about  a  year  later,  show  the  effect  of  a  bodily  labial  movement  of  the  six  upper 


Fig.  205. 


front  teeth,  and  a  complete  restoration  of  the  facial  outlines  and  normal  pose  of  the 
chin,  though  no  appliance  was  placed  on  the  lower  teeth,  except  to  act  as  an  auxiliary 
to  the  upper  for  the  attachment  of  the  intermaxillary  force.  To  show  the  remark- 
able simplicity  in  the  working  possibilities  of  the  regular  bodily  movement  appli- 


CHAPTER  XL.    DIAGXOSIS,  CAUSES,  AND   TREATMENT.    CLASS  III. 


293 


ances,  and  the  ease  and  non-irritability  of  subsequent  treatments,  the  author  wishes 
to  state  that  this  case  was  never  seen  by  him,  except  at  the  time  required  in  pre- 
paring and  stabiHzing  the  appHances,  until  the  patient  came  for  the  retainers. 
The  work  of  adjustment  treatments — which  consisted  in  the  simple  tvirning  of  the 
nuts  at  regular  periods  and  intermaxillary  adjustments — were  wholly  performed 
by  the  young  man  himself  while  pursuing  his  college  course. 

Even  in  those  cases  in  which  the  mandible  is  really  prognathic  in  connection 
with  retruded  uppers,  if  the  lower  lip  is  retruded  in  relation  to  the  chin — showing 

Fig.  206. 


that  the  lower  denture  is  not  also  protruded  with  the  mandible — the  proper  bodily 
correction  of  the  upper,  which  places  the  upper  and  lower  front  teeth  and  the  lips 
in  harmony,  will  invariably  result  in  such  an  improvement  to  the  facial  outlines 
that  the  former  displeasing  prognathism  of  the  mandible  is  lost  sight  of,  and  at 
times  it  is  changed  to  the  beatitifying  effect  of  a  "Gibson  chin." 

This  principle  is  perfectly  illustrated  in  Fig.  205,  which  was  made  from  the 
facial  and  dental  casts  of  a  miss  about  eighteen  years  of  age.  In  connection  with 
the  inherited  prognathism  of  the  mandible,  the  upper  laterals  were  missing  through 
extinction  of  the  tooth  germs,  which  no  doubt  was  the  main  cause  of  the  more 
extensive  upper  retrusion.  The  main  object  in  the  correction  of  this  case,  as  in 
that  of  many  others  of  a  similar  character  whose  pronounced  facial  imperfections 
must  inevitably  mar  the  social  life  and  attractiveness  of  young  ladies,  was  to 
beautify  the  facial  outlines,  though  as  always,  with  the  view  of  leaving  a  good 
masticating  occlusion  of  the  teeth,  even  if  partially  artificial. 

It  can  be  seen  by  comparing  the  palatal  views  of  the  casts  of  the  upper  denture 
before  and  after  treatment,  something  of  the  degree  of  bodily  labial  movement 
that  was  necessary  to  place  the  upper  central  incisors  and  adjoining  cuspids  in  their 


294  PART   VI.    DENTO-FACIAL  MALOCCLUSIONS 

proper  relations  to  the  lower,  and  thus  harmonize  the  dento-faeial  area.  This 
necessitated  opening  spaces  for  the  insertion  of  four  artificial  teeth. 

Far  too  many  cases  of  upper  retrusion  are  caused  wholly  by  the  injudicious 
extraction  or  imnecessary  loss  of  upper  permanent  teeth.  This  is  fully  outlined 
and  illustrated  in  Chapter  XII,  under  the  head  of  "The  Question  of  Extraction." 
In  addition  to  this,  also,  many  of  these  cases  are  caused  by  extinction  of  the  germs 
of  upper  front  teeth,  especially  the  lateral  incisors,  which  permits  the  upper  lip  to 
contrude  the  underlying  front  teeth  in  the  early  years  of  their  development,  so  that 
they  bite  back  of  the  lowers,  causing  also  a  lack  of  normal  anterior  development  of 
the  alveolar  process  which  supports  the  upper  apical  zone  of  the  lip,  with  the  fre- 
quent production  of  all  the  pronounced  characteristics  of  an  upper  retrusion,  even 
to  the  effect  of  a  prognathic  mandible.  This  is  well  illustrated  in  Fig.  206.  The 
illustration  on  the  left  was  made  from  a  small  tin-type  taken  before  treatment,  at 
about  eighteen  years  of  age.  The  one  on  the  right  is  from  a  photograph  taken 
several  years  after  correction.  What  appears  to  be  the  lateral  incisors,  are  the  cus- 
pids, turned  slightly  and  cut  off  to  imitate  the  laterals  in  appearance.  The  first 
premolars,  as  is  usual  in  these  cases,  were  brought  forward  and  turned  to  imitate 
the  cuspids.  Artificial  teeth  were  inserted  between  the  premolars  for  retention 
and  appearance. 

One  of  the  most  prolific  of  the  local  causes  of  upper  retrusions  in  the  author's 
practice,  has  arisen  wholly  or  in  part  from  pharyngeo-nasal  diseases,  resulting 
in  inhibited  development  of  the  maxilla,  and  contracted  retrusions  of  the  upper 
denture.  From  this  cause  may  arise  also  the  early  habit  of  long  continued  mouth- 
breathing,  resulting  in  open-bite  malocclusion.  These  conditions  are  fully  de- 
scribed under  the  practical  treatment  of  Divisions  2  and  3  of  this  Class. 


CHAPTER   XLI 


Fig.  208. 


Division  1,  Class  III 
BODILY  RETRUSION   OF  THE  UPPER  DENTURE  AND   MAXILLA 

Fig.  207.  Division   1    of  this  Class  arises  from  heredity,  and  is 

characterized  by  a  retruded  malposition  of  the  entire 
maxilla  and  upper  denture,  and  produces  a  retrusion  of 
the  entire  upper  lip,  and  frequently  the  end  of  the  nose. 
In  this  Division  is  placed  all  of  that  common  type  of  cases 
of  Class  III  malocclusions  in  which  the  entire  upper  den- 
ture is  bodily  retruded  in  its  dento-facial  relations,  and  the 
chin  and  lower  lip  (mandible  and  lower  denture)  are  in 
normal  relations  to  each  other  and  with  the  main  features 
of  the  physiognomy,  though  frequently  wrongly  diagnosed 
as  prognathic. 

The  dentures  are  commonly  in  fair  alignment,  the  upper 
front  teeth  biting  back  of  the  lowers,  and  the  premolars 
and  molars  in  linguo-distal  malocclusion. 

The  facial 
and  dental 
casts  on  the 
left  of  Fig. 
208  show  a 
perfect  type 
of  this  Divi- 
sion.    Please  note  the  perfect  facial 

outlines  in  the  finished  face  on  the 

right,  even  to  the  straightening  of  the 

nose.    The  dental  models  of  this  case, 

shown  on  the  right  in  this  illustration, 

represent  the   true  relations  of  the 

dentures    in    occlusion    immediately 

upon  removal  of  the  apparatus  which 

was  employed  for  the  bodily  labial 

movement  of  the  upper  front  teeth 

and  the  expansion  of  the  upper  arch, 

also  for  the  retruding  movement  of  the  lower  with  the  intermaxillary  force.    The 

premature  removal  of  the  appliance,  before  the  final  adjustment  of  the  buccal 

295 


29()  PART    VT.     DENTO-FACfAL   MALOCCLUSIONS 

occlusion,  was  made  so  that  impressions  conld  be  taken  for  the  easts  as  shown,  to 
be  exhibited  as  a  part  of  the  illustrations  of  a  jjaix'r  whicli  the  author  read  before 
the  International  Dental  Congress  in  1893. 

This  was  one  of  the  three  eases  which  the  author  presented  at  that  meeting  to 
sliow  the  possibility  and  practicability  of  an  extensive  bodily  labial  movement 
with  the  "contouring  apparatus,"  and  an  extensive  disto-mesial  movement  of  the 
dentures  with  the  intermaxillary  elastic  force.  The  author  has  never  seen  this 
case  since  its  correction,  but  he  learned  from  friends  of  the  family  that  "the  teeth  all 
went  back,"  which  is  not  at  all  surprising  considering  the  extensive  disto-mesial 
movement  of  the  entire  dentures,  and  the  crude  methods  of  retention  then  employed. 

The  main  reason  why  many  cases  of  inherited  upper  retrusion  in  the  author's 
early  practice  seemed  impossible  to  permanently  retain,  was  because  in  the  process 
of  correction,  all  the  teeth  of  the  upper  denture  were  moved  forward  so  as  to  place 
them  in  normal  occlusion.  In  other  words,  the  entire  upper  denture  was  forced 
forward  of  its  natural  inherited  position,  accomphshed  mainly  with  the  intermaxil- 
lary force  as  an  auxiliary  to  the  bodily  labial  movement  of  the  front  teeth.  When 
admissible,  the  lowTr  denture  was  made  to  aid  in  this  occlusal  correction  by  a 
reciprocal  retruding  movement  enabled  through  the  reaction  of  the  elastics,  with 
the  result  that  all  the  teeth  of  both  dentures  were  moved  considerably  from  their 
inherited  locations  with  the  sole  object  of  producing  a  normal  occlusion,  and  with 
the  hope  and  foolish  expectation  that  a  normal  interdigitation  of  buccal  cusps  would 
be  sufficient  to  retain  them  after  a  reasonable  retention  with  a  continuation  of  the 
intermaxillary  force. 

In  a  large  proportion  of  cases,  the  intermaxillary  principle  of  retention  is 
all  right,  and  sufficiently  effective,  but  in  all  strongly  marked  types  of  retrusion 
or  protrusion  which  arise  from  heredity,  the  correction  of  a  mesio-distal  malocclu- 
sion with  the  intermaxillary  force — which  is  always  possible  to  effect — will  almost 
invariably  return  to  its  former  malrelations  after  the  intermaxillary  retention  is 
stopped.  Besides,  when  dependent  upon  this  kind  of  artificial  retention,  it  is  a 
most  unsatisfactory  dernier  resort,  because  patients  will  not  attend  to  its  proper 
application  through  the  many  months  recjuired  for  retention. 

The  modern  reliable  method  for  the  correction  and  permanent  retention  of 
all  cases  of  pronounced  disto-mesial  malocclusion  of  the  dentures  which  are  charac- 
terized principally  by  a  pronounced  dento-facial  protrusion  or  retrusion  of  only  one 
denture,  with  all  the  teeth  in  fair  alignment  and  caused  by  heredity,  is  not  follow- 
ing the  arbitrary  teaching  of  shifting  the  dentures  to  a  normal  occlusion,  but  it 
is  to  move  only  the  front  teeth,  which  are  causing  the  facial  disharmony.  This  is 
accomplished  in  cases  of  decided  retrusions  of  the  upper  or  the  lower  dentures  by 
a  bodily  labial  movement  of  the  front  teeth,  leaving  spaces  between  the  premolars 
for  the  insertion  of  artificial  teeth  for  retention  and  mastication. 

Fig.  209  is  presented  to  emphasize  the  characteristic  facial  type  of  Division  1 
in  this  Class,  and  to  show  the  mature  expression  which  may  be  caused  in  the  physiog- 


CHAPTER   XLI.     DIVISION   1.    CLASS  III. 


297 


nomy  of  a  child  twelve  years  of  age  by  a  retrusion  of  the  entire  upper  lip  and  lower 
portion  of  the  nose,  with  a  concomitant  deepening  of  the  naso-labial  lines.  It  also 
illustrates  why  it  is  at  times  necessary  in  cases  of  upper  retrusion  to  first  force  the 
crowns  partly  forward  of  the  lowers  so  they  can  be  grasped  by  the  power  and  ful- 
crum arch-bows  of  the  contouring  apparatus. 

This  case  was  presented  in  connection  with  a  decided  upper  protrusion  in  the 
chapter  on  Dento-Facial  Diagnosis,  to  show  by  intermedial  facial  casts  the  progres- 

FiG.  209. 


sive  efifect  on  the  facial  outlines,  first,  by  an  inclination  movement  of  the  crowns  of 
the  front  teeth,  and  second,  by  a  bodily  movement.  The  intermediate  facial  casts, 
Fig.  124,  Chapter  XXI,  to  which  the  reader  is  referred,  plainly  show  that  when  the 
crowns  alone  are  moved,  there  is  no  appreciable  movement  of  the  apical  dento- 
facial  zone.  Cases  of  pronounced  upper  retrusions,  which  markedly  show  a  retrusion 
of  the  end  of  the  nose,  must  be  due  to  an  abnormally  retruded  position  of  the  true 
bone  of  the  intermaxillary  process  with  the  nasal  spine  and  cartilaginous  septum 
which  supports  the  end  of  the  nose  in  its  relation  to  the  nasal  and  malar  bones. 
Therefore,  when  the  end  of  the  nose  is  brought  forward  and  its  lines  straightened, 
it  follows  that  the  entire  intermaxillary  bone  with  its  alveolar  process  is  moved 
forward  with  the  bodilv  labial  movement  of  its  contained  teeth. 


CHAFI'KR   XLII 


THE   PROTRUDING   CONTOUR  APPARATUS 

Nearly  all  malocclusions  of  Class  III  demand  a  labial  bodily  movement  of 
the  upper  incisors  and  occasionally  that  of  the  cuspids.  This  movement  of  the 
roots  of  the  incisors  in  phalanx  for  the  younger  class  of  patients  will  usually  cause 
the  surrounding  alveolar  process  to  move  bodily  forward  with  the  teeth.  For  the 
older  class  of  patients,  say  from  fifteen  to  sixteen  years  of  age,  and  later,  the 
Pj^  ,,^y  movement  is  more  of  an  interstitial  na- 

ture— the  roots  often  becoming  quite 
prominent  in  relation  to  the  surface 
of  the  gum.  If  this  becomes  especially 
perceptible,  it  indicates  that  the  amotant 
of  force  that  is  regularly  applied  each 
week  should  be  reduced  so  that  the 
development  of  the  new  alveolar  proc- 
ess will  have  a  chance  to  keep  pace 
with  the  movement  of  the  roots.  It 
is  the  full  normal  development  of  the 
process  that  is  of  the  greatest  impor- 
tance in  completing  and  perfecting  the  framework  to  give  proper  form  and  support 
to  the  corrected  facial  contours. 

Fig.  210  illustrates  the  most  modern  "Contour  Apparatus"  for  the  bodily 
labial  movement  of  the  upper  incisors,  the  mechanical  principles  of  which  in  various 
forms  have  now  been  in  practical  employment  for  about  thirty  years  in  the  success- 
ful correction  of  hundreds  of  cases  of  Class  III  malocclusion. 

In  recent  years,  in  addition  to  the  two  and  three-band  stationary  anchorages 
which  have  aways  characterized  this  apparatus,  the  anchorage  tubes  for  the  power 
arch-bow  have  been  attached  to  root-wise  extensions  as  shown.  This  greatly  increases 
the  mechanical  advantages  and  offers  greater  stability  to  the  anchorages,  as  fully 
explained  in  Chapter  XX.  The  scientific  principles  of  bodily  movement,  partic- 
ularly those  which  relate  to  the  labio-lingual  bodily  movement  of  the  front  teeth, 
outlined  in  Chapter  XIV,  are  worthy  of  the  deepest  study  by  all  who  contem- 
plate this  operaton. 

In  descriptions  and  illustrations  of  this  apparatus  in  previous  chapters,  the 
U-power  tubes  are  open  at  the  top  and  the  threaded  ends  of  the  power  arch-bows 
are  held  in  place  with  counter-sunk  lock  nuts.  A  recently  improved  device  for 
this  purpose  is  shown  in  working  detail  in  Fig.  210,  which  is  less  liable  to  irritate 

298 


CHAPTER  XLII.    THE  PROTRUDING  CONTOUR  APPARATUS  299 

the  tissues  and  presents  greater  facilities  for  assembling  and  locking  the  power 
arch -bow.  The  mesial  end  of  the  U-tube  "a"  is  shaped  to  telescope  into  a  thin 
seamless  tube  "b"  into  which  a  short  section  of  tube  "c"  is  soldered  to  form  a 
shoulder-rest  to  receive  the  thrust  of  the  nut.  In  assembling,  the  completed  thim- 
ble "d"  is  slipped  on  to  the  threaded  end  of  the  power  arch-bow  which  when  placed 
in  its  U-tube  is  then  locked  with  the  thimble  as  shown. 

Usually  in  placing  this  apparatus,  the  fulcrum  arch-bow  is  attached  to  the 
stationary  anchorages,  having  in  mind  only  the  labial  movement  of  the  incisors. 
In  all  extensive  cases,  however,  when  considerable  movement  is  demanded,  it  is 
often  necessary  for  the  correction  of  the  facial  outlines  and  permanency  of  retention 
to  open  spaces  between  the  anterior  bticcal  teeth  for  the  insertion  of  artificial 
retaining  dentures.  The  present  apparatus  shows  how  this  fulcrum  force  may  be 
utilized,  first,  toward  a  mesial  movement  of  the  cuspids,  and  then  the  first  pre- 
molars, so  that  the  artificial  retaining  teeth  will  be  as  inconspicuous  as  possible. 
This  method  particularly  applies  to  the  extensive  movements  demanded  in  Division 
1  of  this  Class  and  in  Division  1  of  Class  II  where  the  teeth  of  the  retruded  dentures 
at  the  beginning  of  the  operation  are  in  fair  alignment. 

In  the  Construction  of  this  apparatus,  the  teeth  should  be  properly  separated 
and  each  finished  band  and  anchorage  so  perfectly  fitted  that  it  can  be  easily  forced 
on  and  oft'  with  the  aid  of  a  wood  plugger  and  band  removing  plier — shown  in  Figs. 
98  and  99,  Chapter  XIX — in  making  slight  but  necessary  changes  in  the  shape  or 
position  of  the  attachments  or  power  arch-bow.  The  size  of  the  power  arch-bow 
for  extensive  movements  should  rarely  be  larger  than  No.  16  (.050")  spring  nickel 
silver.  It  should  be  bent  first  upon  the  model,  and  finally  at  the  chair,  to  conform 
to  the  shape  of  the  arch,  its  ends  lying  evenly  in  the  power  tubes  without  the  slightest 
tension.  In  the  final  moves  of  this  important  requirement,  place  the  anchorages  in 
position  and  the  power  arch-bow  with  the  threaded  ends  lying  along  the  outside  of  the 
tubes.    Then  place  the  right  end  in  its  tube,  and  see  that  the  other  end  lies  exactly 

parallel  with  the  left  tube  and  in  proper  shape 
^"^-  -^1-  and  position  in  front.   Then  place  the  left  end 

in  its  tube  with  the  other  end  free,  and  go 
through  the  same  movements.  This  may  re- 
quire repeating  several  times  with  the  great- 
est nicety  of  judgment  and  patience  in  detail, 
before  you  are  able  to  assemble  the  power 
arch-bow  and  anchorages  properly  together. 
The  heaw  bending  pliers,  Fig.  211,  are  indis- 
pensable for  this  operation. 

After  the  preliminary  fitting  of  the  anchor- 
ages, they  may  be  cemented  and  the  power  arch-bow  placed  in  position.  In  assem- 
bling the  bow,  place  the  left  end  in  its  closed  tube  and  carry  the  other  end  around 
beneath  the  chin  and  up  into  the  right  corner  of  the  mouth  back  to  its  position  in 


300  PART    VI.     DENTO-FACIAL   MALOCCLUSIONS 

the  U-tubc,  locking  it  in  place.  It  is  at  this  time  that  its  final  adjustments  should 
be  made  in  its  relation  to  the  line  of  the  labial  gum  and  gingival  line  of  the  incisor 
attachments.  If  the  dental  arch  requires  lateral  expansion  or  contraction,  the 
power  bow  when  fitted  may  be  sprung  so  as  to  exert  a  slight  force  in  a  l)uccal  or 
lingual  direction. 

When  this  is  accomplished,  the  final  preliminary  fitting  of  the  incisor  bands 
should  be  made.  Each  band  should  be  carried  fully  to  place  with  its  root-wise 
extension  lapping  on  to  the  power  bow.  It  will  now  be  seen  whether  the  bow  rest- 
ing in  its  anchorage  tubes  is  too  high  or  too  low  to  take  its  place  without  tension  in 
relation  to  the  root-wise  extensions.  It  will  also  be  found  that  these  extensions 
will  need  to  be  bent  lingually  or  labially,  and  the  upper  ends  cut  off  and  finished 
slightly  above  an  even  line  with  the  upper  border  of  the  power  bow.  They  should 
perfectly  fit  against  the  labial  surface  of  the  bow,  but  in  no  sense  to  lap  above  it, 
as  this  would  prevent  their  easy  removal  in  case  it  became  necessary.  The  fitting, 
bending,  filing,  and  polishing  of  this  special  attachment  without  distortion  or  injury 
to  the  band  is  difficult  without  the  use  of  the  root-wise  plier,  Fig.  112,  Chapter  XX. 

Treatment  Adjustments. — In  applying  the  force  which  is  to  follow  the  first 
conscious  tension  of  the  nuts,  the  large  nuts  of  the  power  bow  should  be  given  about 
two-quarter  turns  three  times  a  week.  As  the  movement  advances  it  will  become 
necessary  to  unscrew  the  fulcrum  nut  occasionally  to  allow  the  incisal  zone  to  move 
forward  with  the  roots.  If  the  roots  are  found  to  be  moving  dangerously  fast  for 
the  safety  of  their  vitality,  the  application  of  force  should  be  stopped  in  the  power 
bow,  and  if  necessary,  the  nuts  may  be  slightly  unscrewed.  Unscrewing  the  nut 
upon  the  fulcrum  arch-bow  is  also  equivalent  to  reducing  the  force  upon  the  roots. 
It  may  be  advisable  to  remove  the  fulcrum  arch-bow  entirely,  to  be  replaced  with  a 
new  one  when  the  danger  is  past.  The  danger  line  will  be  indicated  by  unusual 
sensitiveness  to  heat  and  cold  over  the  root  or  roots  of  the  affected  tooth  or  teeth ; 
this  should  not  be  allowed  to  arrive  to  a  continual  pain.  Perfect  rest  should  be 
aft'orded  to  the  teeth,  and  the  gum  painted  with  strong  tincture  of  iodine  two  or 
three  times  a  week  until  all  irritation  subsides. 

Those  who  have  followed  closely  the  directions  will  realize  something  of  the 
difficulties  and  skill  necessary  for  the  bodily  labial  movement  of  the  front  teeth, 
and  the  correction  of  facial  contours.  The  author  wishes  to  say  that  unless  the 
operation  is  considered  of  sufficient  importance  to  give  to  it  the  same  painstaking 
skill  that  is  demanded  in  other  branches  of  dentistry,  it  had  better  not  be  attempted, 
as  in  all  probability  it  will  prove  a  failure.  This  refers  not  alone  to  the  construc- 
tion and  application  of  the  regulating  apparatus,  but  to  the  construction  and 
attachment  of  the  proper  retaining  appliance  that  is  intended  to  permanently  sus- 
tain the  position  gained.  On  the  other  hand,  the  truly  wonderful  work  which  this 
single  apparatus  has  accomplished  in  the  author's  hands,  proved  now  by  hundreds 
of  sticcessful  eases,  convinces  him  that  its  work  in  other  hands  will  cause  this 
principle  to  grow  into  great  possibilities. 


CIHL^PTKR    XLIII 

Division  2,  Class  III 

CONTRACTED   RETRUSION    OF   THE   UPPER   DENTURE 

Division  2  presents  qtiite  a  variety  of  dental  malpositions  which  arise  mostly 
from  local  catises,  all  of  which  present  the  same  peculiar  facial  expression  that  is 
characteristic  of  Class  III.  Contracted  retrusions  of  the  upper  denture  are  due  to 
two  main  causes:  First,  from  adenoids,  etc.,  inhil)iting  the  growth  development  of 
the  maxilla,  which  thus  does  not  give  sufficient  room  for  the  proper  eruption  of  the 
permanent  teeth  in  the  contracted  maxillary  arch.  In  conseciuence  of  this,  the 
teeth,  and  particularly  the  cuspids,  are  forced  out  of  alignment,  or  impacted,  with 

Fig.  212. 


the  producton  of  a  dental  and  alveolar  arch  that  is  contracted  in  its  dimensions 
in  relation  to  the  normal.  The  second  form  is  caused  by  injudicious  extraction, 
or  the  premature  loss  of  the  deciduous  teeth  through  extensive  decay,  or  the  lack 
of  permanent  teeth  from  extinction  of  the  tooth  germs. 

When  any  of  these  local  causes  are  ingrafted  upon  an  inherited  upper  retru- 
sion,  they  proportionately  increase  the  dental  malposition  and  facial  deformity. 
Combinations  of  local  causes  and  inherited  retrusions  result  in  many  of  the  most 

301 


302 


PART    17.     DKXrO-FACf.lL   MALOCCIJ'SfONS 


pronounced  dento-facial  malocclusions  of  this  Class,  some  of  which  are  illustrated 
in  Division  3. 

In  Chapter  XL,  the  case  illustrated  by  Fig.  204  was  caused  by  the  very  early 
loss  of  the  upper  first  permanent  molars,  and  those  cases  illustrated  in  Figs.  205 
and  206  in  the  same  chapter  were  partly  caused  through  an  extinction  of  the  germs 
of  the  upper  lateral  incisors.     The  most  prolific  of  the  local  causes,  however,  start 

Fig.  213. 


during  very  early  childhood  with  adenoids,  followed  by  pathogenic  conditions 
of  the  naso-maxillary  sinuses.  In  these  cases,  the  maxilla  and  its  entire  upper  dental 
and  alveolar  arch  is  contracted,  with  high  and  narrow  palatal  dome,  and  usually 
with  a  bodily  retrusion  of  the  incisor  teeth  and  intermaxillary  bone. 

This  common  character  of  malocclusion  is  well  shown  in  the  beginning  dental 
and  facial  casts  of  Fig.  212.  The  intermediate  dental  casts  show  the  front  teeth 
in  position  for  the  attachment  of  the  apparatus  for  the  bodily  labial  movement 
of  the  incisors.     The  final  dental  and  facial  casts  were  made  upon  the  removal  of 


CHAPTER  XLIII.    DIVISION  2.    CLASS  III.  303 

this  apparatus,  and  show  the  teeth  in  position  for  the  retaining  appHance  on  the 
front  teeth,  and  the  final  adjustment  of  the  buccal  occlusion.  Cases  of  this  charac- 
ter at  a  youthful  age  rarely  take  over  one  year  to  correct. 

In  many  cases,  the  effect  of  adenoids  will  result  in  inhibited  maxillary  develop- 
ment of  the  intermaxillary  portion  of  the  bone  only.  When  this  causes  the  early 
erupting  incisors  to  close  back  of  the  lowers,  inlocking  them  in  that  malposition 
and  preventing  the  development  of  all  the  incisive  portion  of  the  bone,  it  produces 
all  the  characteristics  of  an  upper  retrusion,  notwithstanding  the  normal  occlusion 
of  the  buccal  teeth. 

This  is  fully  shown  in  Fig.  213  which  illustrates  a  case  that  belongs  to  Class  I,  as 
may  be  seen  by  the  normal  disto-mesal  relations  of  the  buccal  occlusion  at  the  begin- 

FiG.  214. 


ning  of  the  operation.  It  is  presented  in  this  Class,  because  of  its  similarity  in  facial 
characteristics  and  demands  of  treatment.  It  can  be  seen  by  the  dental  cast  made 
before  treatment  that  the  cuspids  are  crowded  out  of  alignment.  But  the  bodily  re- 
truded  position  of  the  incisors  ( shown  by  their  normal  inclination )  and  lingual  alveolar 
ridge  plainly  indicates  that  the  inhibiting  causes  operated  only  in  that  locality. 

The  final  facial  and  dental  casts  show  most  perfectly  the  action,  effect,  and 
possibilities  of  a  bodily  labial  movement  of  the  upper  incisors,  which  in  this  case 
carried  the  entire  incisive  alveolar  ridge  forward  with  the  movement  of  the  roots, 
as  shown  in  the  enlarged  occlusal  aspects  of  the  dentures.  This  case  was  begun  in 
1892,  and  when  finished,  the  casts  were  mounted  and  exhibited  at  the  August, 
1893  meeting  of  the  International  Dental  Congress.  The  profile  photograph  was 
taken  two  or  three  years  afterwards. 

Fig.  214  was  made  from  a  photo-print  of  the  original  apparatus  mounted 
on  a  set  of  the  finished  dental  casts.  It  will  be  noticed  that  the  power  arch-bow 
was  flattened  or  "ribboned"  over  the  incisive  area. 

One  of  the  objects  in  the  exhibition  of  this  and  other  cases  from  the  early 
practice  of  the  author,  is:  It  will  ful]\-  disprove  the  somewhat  prevalent  assumption 


304  /MA'/'    17.     DENTO-FACIM.    M  A /.OCCLi'S/ONS 

that  the  Ixxlily  movement  of  teeth  arose  with  the  intro(hielion  of  the  Anj^'le  "pin 
and  tube"  appliances  of  eomiiaratively  recent  date.  Il  will  also  show  the  practical 
application  and  common  employment  of  the  disto-mesial  intermaxillary  force, 
which  was  first  published  in  connection  with  the  publication  of  the  birth  of  bodily 
movement. 

Fig.  215  illustrates  a  case  which  no  doubt  started  with  the  premature  extraction 
or  natural  loss  of  the  deciduous  front  teeth,  followed  with  the  retrusive  malposition 
of  the  erupting  incisors  to  such  an  extent  that  the  mandil)le  was  forced  to  bite  the 

Fig.  216. 


lower  incisors  in  front  of  the  uppers  to  obtain  a  masticating  occlusion  of  the  back 
teeth.  This,  in  its  developing  stage  caused  a  lack  of  development  of  the  incisive  or 
"intermaxillary"  process,  impacting  the  cuspids,  and  a  protrusive  malposition  of 
the  lower  front  teeth,  resulting  in  a  retrusion  of  the  entire  upper  dento-facial  area, 
and  a  slight  prominence  of  the  lower  lip,  as  seen  by  the  beginning  facial  cast. 

Up  to  the  time  of  the  publication  of  the  first  edition  of  this  work  in  1908, 
it  was  the  common  teaching  in  certain  schools  of  orthodontia  that  "the  theory" 
of  bodily  movement  of  teeth  was  of  no  practical  value.  This  was  emphasized  with 
the  fantastic  claim  that  when  the  crowns  of  the  teeth  were  moved  to  place,  the  roots 
would  soon  follow,  and.  the  facial  outlines  would  develop  to  their  most  harmonious 
possibilities.  Notwithstanding  the  persistent  efforts  of  the  author  to  counteract 
this  claim,  it  prevailed  among  a  majority  of  orthodontists  for  over  twenty  years 
after  the  first  introduction  and  repeated  publication  of  the  present  accepted  true 


CHAPTER  XLHI.     DIVISION  2.     CLASS   III.  305 

principles.  Through  this  influence,  and  the  influence  of  that  equally  erroneous 
teaching  that  no  teeth  should  ever  be  extracted,  the  advancement  toward  the 
higher  principles  and  practice  of  orthodontia  has  been  greatly  retarded.  But 
fortunately  for  the  world,  the  brighter  rifts  of  truth  are  now  fast  dissipating  the 
clouds  which  so  long  prevented  many  people  from  enjoying  the  privileges  of  the 
most  advanced  principles  of  dento-facial  orthopedia. 

In  every  instance  where  an  ordinary  expansion  arch-bow  is  employed  for 
correcting  the  position  of  incisors  that  are  much  retruded,  the  apical  ends  of  the 
roots  and  the  incisive  process  are  never  moved  forward ,  with  the  result  that  when 
the  case  is  discharged,  the  crowns  of  the  teeth  are  in  decided  labial  inclination, 
and  the  facial  depression  is  far  from  corrected.  Where  such  an  inclination  move- 
ment of  the  incisor  teeth  in  these  cases  has  been  accomplished  for  patients  not  older 
than  twelve,  and  the  incisal  edges  retained  in  that  position,  the  developing  in- 
fluences of  growth  will  perhaps  in  some  cases  improve  the  retruded  position  of  the 
roots  and  alveolar  process,  but  even  that  is  always  problematical ;  whereas,  a  bodily 
protruding  movement  of  the  roots  of  the  upper  incisors  and  the  entire  incisive 
process,  with  a  perfect  correction  of  facial  contours  can  be  accomplished  with  ease 
and  with  perfect  certainty  at  any  time  between  ten  and  eighteen  years  of  age.  At 
later  ages,  the  roots  of  the  upper  incisors  can  always  be  moved  bodily  forward, 
and  if  retained  in  that  position,  the  alveolar  process  will  fill  in  around  them, 
though  the  movement  of  the  bone  above,  which  supports  the  base  and  end  of  the 
nose,  may  not  always  respond  to  this  protruding  movement,  in  consequence  of 
which  the  facial  retrusion  is  not  wholly  corrected. 

The  reactive  distal  force  upon  the  anchorages  in  the  bodily  labial  movement 
of  the  front  teeth  demands  the  most  stationary  two  or  three-band  anchorages. 
From  this  need  arose  the  invaluable  root-wise  attachments  which  in  recent  years 
have  characterized  nearly  all  the  bodily  movement  anchorages  in  the  author's 
practice.  It  seems  strange,  therefore,  that  in  a  recent  paper  read  by  a  prominent 
orthodontist  before  the  American  Society  of  Orthodontists,  that  these  great 
principles  are  still  ignored  and  the  single  clamp-band  anchorages  are  advocated  for 
all  purposes. 

It  will  be  noticed  in  all  of  these  cases  that  the  incisors  have  been  brought 
forward  to  a  perfectly  normal  inclination,  while  in  the  final  facial  casts  the  upper 
lips  and  entire  upper  apical  zones  have  been  restored  to  normal  contour,  showing 
that  something  more  than  the  alveolar  process  alone  has  been  moved. 

Figs.  216  and  217  are  quite  typical  of  this  Division  of  malocclusion,  both  having 
been  caused  by  inhibited  development  of  the  maxillae  from  adenoids.  It  is  a  great 
pleasure  to  again  present  these  two  cases,  because  of  the  privilege  it  permits  of 
quoting  the  words  of  that  most  highly  respected  and  beloved  brother  dentist,  the 
late  Dr.  Geo.  H.  Gushing,  who  referred  these  cases  to  the  author  and  opened  the 
discussion  on  the  paper  read  before  the  Tri-State  Dental  meeting  at  Detroit  in 
1895.     Goming  from  "Uncle  George,"  whf)  will  always  he  revered  for  his  ability 


306 


PART    17.     DENTO-l-.\CIM.    MALOCCLUSIONS 


and  outspoken  honesty  of  convictions,  it  reflects  great  honor  upon  this  work 
to  be  able  to  republish  his  words  founded  upon  intimate  clinical  observation  of  the 
progress  and  treatment  in  these  two  cases  of  dento-faeial  deformity. 

"I  am  not  aware  that  there  can  Ix'  much  discussion  upon  a  paper  of  this  charac- 
ter. I  do  not  know  that  there  are  any  technical  objections  to  the  position  that 
the  paper  assumes  as  to  the  possibility  of  moving  the  teeth  in  phalanx  bodily,  the 
sockets  as  well  as  the  teeth.  If  there  are  any  such  objections,  they  must  fall  before 
the  positive  evidence  of  clinical  observation.  I  think  the  paper  shows  conclusively 
that  as  Dr.  Farrar  remarked,  'this  demonstrates  an  era  of  advance  in  orthopedic 

Fk;.  21(1. 


surgery.'  I  think  we  are  most  indebted  to  Dr.  Case  for  an  intelligent  study  of  the 
mechanical  principles  which  govern  the  movements  of  the  teeth  by  applied  force, 
in  connection  with  the  fact  which  he  has  demonstrated,  of  the  possibility  of  moving 
the  teeth  and  the  processes  together.  You  have  seen  what  he  has  accomplished, 
and  these  models  and  drawings  speak  more  eloquently  than  any  language  can 
express. 

"Two  of  these  cases  I  have  seen  under  treatment  from  the  first.  I  cannot 
begin  to  tell  you  the  extent  of  the  improvement  in  the  facial  expression  of  the  young 
lady  illustrated  with  the  plaster  casts  (Fig.  216).*  The  maxillary  bone  and  the 
process  were  so  receded  that  there  were  depressions  each  side  of  the  median  line  so 
deep  that  you  could  lay  your  finger  in  them.     These  are  now  very  nearly  two- 

*The  case  which  Dr.  Gushing  first  called  attention  to  is  that  of  a  girl  about  sixteen  years  of  age.  The  illustration 
shows  the  case  only  partially  completed. 


CHAPTER   XIJII.     DIVISION  2.     CLASS   III. 


307 


thirds  obliterated,  I  should  think,  and  though  this  mask  shows  a  wonderful  im- 
provement, it  does  not  show  fully  the  great  change  which  has  been  effected,  though 
he  has  told  you  that  this  was  one  of  the  cases  so  difficult  to  manage  because  of  the 
rapid  absorption  of  the  process  from  the  pressure  of  the  roots.  I  think  he  hopes  in 
time  to  entirely  obliterate  the  deep  depression  under  the  alse  of  the  nose.  From  my 
observation,  so  far  as  the  case  has  progressed,  I  have  no  doubt  that  he  will  succeed. 
"Of  the  other  case  (Fig.  217),  I  may  say  that  these  casts  do  not  begin  to  show 
the  improvement  that  has  taken  place  in  the  short  time  in  which  the  patient  has 
been  under  treatment.     The  boy  presented  a  very  disagreeable  aspect,  as  you  see 

Fig.  217. 


here.  There  is  one  feature  of  the  case  which  the  author  of  the  paper  did  not  refer 
to.  I  do  not  know  whether  it  passed  his  mind  or  not.  but  it  is  a  feature  which  is 
very  striking.  The  boy  had  a  habit  of  dropping  his  mouth  open  continually.  He 
does  not  do  this  at  all  now.  I  do  not  know  why  the  movement  of  these  teeth  and 
the  contouring  of  the  face  by  this  application  of  force  should  have  produced  that 
change,  but  it  is  a  fact  that  it  has.  The  boy  now  keeps  his  mouth  closed  as  other 
people  do.  With  his  chin  apparently  protruding,  owing  to  the  lack  of  development 
of  the  superior  maxillary,  and  the  mouth  open  all  the  while,  you  may  imagine  how 
very  unpleasantly  he  must  have  presented  himself  to  his  friends.  He  is  now  a  pretty 
respectable  looking  boy,  and  he  was  very  far  from  that  when  he  first  went  into 
Dr.  Case's  hands." 

Notwithstanding  the  perfect  result  shown  in  this  case  and  the  permanency 
of  its  retention,  which  was  perfectly  sustained  with  a  bridge  denture  constructed 


308  I'ART    VI.     DEMV-l'ACIM.   MALOCCLUSIONS 

by  Dr.  Cvishing,  when  the  patient  was  sixteen  years  of  age,  the  mandible  commenced 
to  develop  unusual  proportions,  which  at  nineteen,  had  carried  the  occlusion  of 
the  lower  labial  teeth  again  far  in  front  of  the  uppers.  When  this  unexpected  move- 
ment commenced,  tlie  upper  contouring  apparatus  was  again  attached,  with  its 
auxiliary  the  intermaxillary  force,  with  the  hope  that  an  additional  forward  move- 
ment of  the  upper  teeth  with  a  retruding  movement  of  the  lowers  would  correct 
the  condition,  but  this  was  soon  found  impossible,  because  of  the  pronounced  prog- 
nathism which  the  mandible  was  assuming.  This  peculiarity  of  the  forces  of  hered- 
ity assuming  sway  in  the  later  years  of  adolescence,  is  mentioned  at  greater  length 
in  other  chapters. 

For  the  purpose  mainly  of  showing  the  great  possibilities  in  bodily  movements 
of  teeth  under  favorable  conditions  of  health,  with  the  application  and  control  of 
the  various  forces,  the  author  has  decided  at  the  last  moment  to  publish  in  this 
work  a  brief  history  of  a  case  in  which  the  movement  has  been  so  great  and  yet 
free  from  all  unhealthful  disturbances  of  the  teeth,  that  one  can  hardly  believe  it 
possible.  This  case  was  commenced  about  seven  years  ago  at  the  age  of  ten  years, 
and  has  since  been  treated  in  interrupted  stages  according  to  the  demands  of 
physiologic  movement,  and  with  the  view  of  stimulating  to  the  greatest  extent 
a  revivification  of  inhibited  growth  development. 

As  the  extent  of  bodily  movement  in  this  case  has  been  so  great  that  few  would 
be  willing  to  believe  it  possible  without  seeing  the  patient  and  without  having 
an  opportunity  to  examine  the  plaster  models  from  the  beginning  of  the  work 
through  the  different  stages  of  development,  the  author  invited  all  the  orthodon- 
tists of  Chicago  and  surroundings  to  a  clinic  on  February  3,  1921,  at  which  time 
this  case  was  fully  presented.  Besides  the  fourteen  orthodontists  who  were  present 
on  that  occasion,  a  number  of  prominent  Chicago  dentists  have  been  in  touch, 
more  or  less,  with  this  case  during  its  treatment. 

In  Fig.  2173'2  is  shown  the  illustrations  of  the  facial  and  dental  plaster  casts 
made  at  the  beginning  of  the  operation,  and  again  shortly  before  the  above  clinic. 
One  cannot  appreciate  the  perfectipn  of  this  case  without  meeting  the  patient, 
now  a  beautiful  young  lady  about  eighteen  years  of  age,  whose  natural  facial  en- 
dowments and  perfect  form  and  color  of  teeth,  gave  a  most  favorable  foundation 
upon  which  to  build  the  present  successful  result. 

In  viewing  the  three  stages  of  the  movement  shown  in  the  palatal  views,  please 
note  in  the  beginning  model  of  the  upper  denture  (a)  at  the  left,  the  distances 
from  the  lateral  incisors  to  the  first  premolars ;  then  to  the  second  premolars ;  and 
finally,  to  the  first  molars;  and  then  compare  this  to  the  final  model  of  the  upper 
at  the  right  (c)  which  contains  the  same  teeth,  and  in  addition,  the  cuspids. 

At  the  beginning  of  the  operation,  the  actual  distance,  according  to  the  models, 
between  the  upper  left  lateral  and  first  permanent  molar  in  May,  1914,  was  ^  of 
an  inch,  and  in  December,  1920,  it  was  iH  inches,  showing  the  remarkable  dis- 
tance of  bodily  separating  movement  of  %  of  an  inch  between  these  teeth  and 


CHAPTER   XLIII.     DIVISION  2.     CLASS  III. 


309 


without  the  shghtest  inchnation  or  tipping  movement.  On  the  right  side,  the 
movement  was  about  the  same,  but  not  completed  at  that  time.  And  through 
the  whole  operation  the  teeth  and  gums  have  remained  in  a  perfectly  healthy 
normal  condition. 

Fig.  2\7]4. 
a  b  c 


The  above  illustration  was  made  by 
pressing  modeling  compound  against 
the  labio-buccal  surfaces  of  the  teeth 
while  the  jaws  were  closed,  and  shows 
the  appearance  of  the  left  side  with 
the  retaining  bridge  denture  in  place 
at  the  time  of  the  clinic.  The  upper 
teeth  back  of  the  cuspid  are:  (1)  the 
artificial  premolar.  (2)  the  first  pre- 
molar. (3)  the  artificial  molar.  (4)  the 
second  premolar,  and  (5)  the  first 
molar. 


The  facial  casts  were  made  at  ten  and  seventeen  years  of  age.  The  front  occlusal 
models  were  made  from  modeling  compound  impressions  pressed  against  the  front 
teeth  with  the  dentures  in  masticating  occlusion. 

It  is  not  assiomed  that  this  extraordinary  movement  consisted  wholly  in  a 
bodily  labial  movement  of  the  upper  front  teeth,  although  every  effort  was  em- 


310  PART    VI.     DENrO-FACIAL   MALOCCLUSIONS 

ployed  to  prevent  a  distal  movement  of  the  back  teeth  by  locking  the  three  buccal 
teeth  on  each  side  in  stationary  anchorages  carrying  power  root-wise  attachments,  in 
connection  with  the  constant  application  of  intermaxillary  force.  Nor  is  it  claimed 
that  the  extent  of  this  movement  was  wholly  mechanical,  but  rather  one  which  was 
greatly  aided  by  the  extensively  restored  growth  of  the  maxilla  through  the  stimu- 
lated revivification  of  the  inhibited  and  dormant  activities  of  normal  development. 
It  is  possible  that  a  slight  distal  movement  of  the  anchorage  teeth  may  have 
caused  a  retardation  in  the  eruption  of  the  second  molars,  which  only  now  are  about  to 
come  through  the  gums — shown  by  radiographs.  This  sluggish  eruptive  movement, 
however,  has  been  characteristic  of  the  entire  case  from  the  beginning,  and  no  doubt 
was  caused  by  the  same  forces  that  inhibited  the  development  of  the  maxilla  and 
the  germination  of  six  teeth. 

At  the  time  of  the  clinic,  the  patient  was  wearing  the  usual  six-band  labial 
retainer  with  lingual  spring  bars  locked  in  molar  anchorages  that  are  always  placed 
to  retain  bodily  movements  of  the  front  teeth.  On  the  left  side,  the  spring  bar  was 
connected  with  the  permanent  retaining-bridge  denture  which  supplied  the  spaces 
with  porcelain  teeth  (d).  On  the  right  side,  the  patient  was  still  wearing  an  appli- 
ance for  the  bodily  mesial  movement  of  the  first  premolar,  the  same  as  that  which 
was  worn  on  the  left  side  in  spacing  for  the  artificial  teeth. 

As  previously  mentioned,  all  the  upper  buccal  teeth  on  each  side  were  employed 
for  stationary  anchorages  for  the  bodily  labial  movement  of  the  front  teeth.  But 
toward  the  latter  part  of  the  operation,  the  first  premolars  were  cut  loose  from  the 
anchorages,  to  place  them  in  more  proper  positions  for  the  ultimate  retaining-bridge 
dentures.  In  this,  as  in  other  bodily  movements,  in  order  to  keep  the  teeth  in  an 
upright  position,  it  was  necessary  to  apply  the  force  upon  root-wise  attachments. 

This  case  at  ten  years  of  age  was  a  very  peculiar  one  and  presented  a  pros- 
pect of  almost  insurmountable  difificulties  in  the  decided  inhibited  development 
of  the  maxilla;  the  retarded  eruption  of  the  permanent  teeth;  no  molars  on  the 
lower  except  what  seemed  to  be  the  second  permanent  molars,  which  recent  radio- 
graphs show  to  be  the  only  molars  on  the  lower ;  no  masticating  occlusion  to  speak 
of;  and  the  lower  incisors  closing  nearly  a  half -inch  in  front  of  the  uppers.  Note  the 
beginning  stage  of  the  lower  teeth  and  the  wide  abnormal  interproximate  spaces 
which  had  arisen  without  cause  and  with  no  possible  occlusion  except  upon  the 
prematurely  erupted  second  molars.  Even  after  the  premolars  and  cuspids  com- 
menced to  erupt,  their  growth  was  so  slow  and  apparently  inhibited  with  unnatural 
spacing  of  the  teeth,  that  the  extrusive  force  to  correct  the  decided  infra-occlusion 
of  the  buccal  teeth  in  this  case  was  fraught  with  as  much  difificulty  and  discourage- 
ment as  any  part  of  the  operation.  Because  of  these  unusual  peculiarities,  the  main 
object  has  been  to  correct  the  facial  deformity  by  placing  the  front  teeth  and 
their  alveolar  processes  in  perfect  position  so  as  to  present  a  fine  appearance,  and 
to  do  the  best  that  could  be  done  with  the  back  teeth  to  place  them  in  position 
for  bridge  dentures,  to  secure  proper  masticating  occlusion. 


CHAPTER  XLIII.     DIVISIOX    L     CLASS   III.  311 

In  all  cases  of  this  Class,  the  intermaxillary  force  is  invariably  employed  as  an 
indispensable  adjunct  to  support  the  stability  of  the  upper  anchorages.  A  regular 
six-band  labial  retaining  appliance  with  intermaxillar\-  hook  attachments  forms 
an  admirably  stable  anchorage  for  this  force,  the  application  of  which  no  doubt 
prevented  the  lower  teeth  from  being  carried  forward  in  the  growth  of  the 
mandible,  so  that  now  they  are  in  esthetic  relation  to  the  chin  with  the  produc- 
tion of  that  very  desirable  labio-mental  curve.  Other  than  this,  no  attempt  has 
been  made  to  fully  regulate  the  lower  denture,  because  the  spacing  of  the  teeth 
could  be  easily  accomplished  at  any  time  when  it  seemed  desirable  to  make  a 
lower  artificial  denture.  The  main  object  in  this  case  has  been  to  adjust  the 
upper  and  lower  molar  and  premolar  occlusion  to  the  best  advantage  for  sub- 
sequent dentures. 


chapii>:r  xliv 

Division  3,  Class  III 
UPPER   RETRUSION   WITH   PROTRUSION   OF   LOWER   DENTURE 

I'iG.  21S.  In  Division  3  of  this  Class,  the  lower  denture  is 

protruded  in  relation  to  the  mandible  with  the  partial 
or  complete  obliteration  of  the  labio-mental  depression. 
It  will  be  remembered  that  this  same  character  of  lower 
relations,  producing  a  receding  chin  effect,  is  exactly 
that  which  is  found  in  bimaxillary  protrusions  of 
Class  I. 

There  is  really  no  local  cause  that  can  produce  a 
protrusion  of  the  lower  denture  in  relation  to  the 
mandible,  which  commonly  occurs  with  the  upper  den- 
ture in  relation  to  the  maxilla — frequently  from  local 
causes  explained  elsewhere;  therefore,  this  particular 
character  of  the  lower  must  always  arise  from  heredity, 
though  the  retruded  upper — if  it  is  retruded — may 
arise  from  other  causes. 

When  the  cause  of  "heredity"  is  mentioned,  it  is 
hoped  that  the  student  from  the  previous  teaching 
will  understand  that  it  does  not  necessarily  mean  a 
direct  inheritance  of  that  particular  condition  from  a 
parent,  which  of  course  is  possible;  nor  does  it  necessa- 
rily mean  the  direct  inheritance  of  types  which  are 
inharmonious  when  combined  in  the  offspring,  because  the  term  heredity  applies 
to  a  law  of  generation  which  is  expressed  in  a  variety  of  ways,  as  has  been  fully 
outlined  in  chapters  relative  to  the  etiology  of  malocclusion. 

Treatment 

If  the  malocclusion  is  slight  in  this  Division,  and  caused  partly  by  the  retruded 
upper,  for  patients  younger  than  twelve  or  fourteen  years  of  age,  the  dentures 
should  be  placed  in  normal  occlusion  with  the  reciprocal  action  of  the  intermaxillary 
force,  the  student  bearing  in  mind  that  the  natural  growth  development  of  the 
mandible  and  other  bones  of  the  physiognomy  is  constantly  diminishing  child- 
hood's protruding  disharmonies  of  the  teeth. 

In  a  pronounced  protrusion  of  the  lower  denture  in  relation  to  the  mandible 
and  dento-facial  harmony,  as  in  pronounced  upper  protrusions,  if  it  can  be  seen 

312 


CHAPTER  XLIV.     DIVISION  3.     CLASS  III  313 

that  it  has  arisen  from  a  marked  hereditary  strain,  the  extraction  of  the  first  lower 
premolars  is  advisable,  to  be  followed  with  the  same  rules  of  treatment  as  for  pro- 
truded uppers.  The  regulation  of  the  upper  should  be  guided  by  the  character 
and  degree  of  retrusion,  while  a  perfect  disto-mesial  and  bucco-lingual  interdigi- 
tation  of  buccal  cusps  goes  without  saying. 

The  qmte  remarkable  improvement  to  the  facial  outlines  in  these  cases  by  the  pro- 
trusive movement  of  the  upper  and  the  retrusive  movement  of  the  lower,  is  shown  by 
the  profile  casts  of  the  finished  cases.  This  is  no  more  than  any  orthodontist  may 
easily  obtain  in  all  cases  by  a  scientific  application  of  mechanical  force,  accompanied 
with  a  rational  acceptance  of  necessities,  and  an  appreciation  of  the  highest  attain- 
ments in  facial  as  well  as  dental  art . 

Fig.  219. 


Fig.  219  represents  a  case  which  has  been  especially  chosen  from  many  of 
this  Division  of  malocclusion  in  the  author's  practice,  to  illustrate  the  practical 
applicability  of  the  foregoing  statement.  It  was  made  from  the  facial  and  dental 
casts  of  a  woman  twenty-four  years  of  age,  and  represents  one  of  the  most  pro- 
nounced and  difficult  cases  of  this  type  which  the  author  has  ever  been  called  upon 
to  treat.  Every  feature  of  the  physiognomy  outside  the  dento-facial  area  was  per- 
fect, which  in  connection  with  the  dark  brown  hair,  beautiful  eyes,  and  smooth 
olive  complexion,  gave  one  the  greatest  desire  to  correct  the  deformed  area  caused 
by  the  malocclusion.  The  occlusion  of  the  teeth  was  so  imperfect  that  a  healthful 
mastication  of  food  was  impossible.  The  main  object  of  treatment,  however,  was 
to  get  rid  of  the  facial  deformity  (which  she  had  borne  for  so  many  years,  not  know- 
ing that  any  correction  was  possible). 


314 


PART   VI.    DENTO-FACIAL  MALOCCLUSIONS 


Fig.  220. 


In  order  to  accomplish  this,  the  case  was  started  by  extracting  the  first  lower 
premolar  on  the  right,  and  a  decayed  lower  molar  on  the  left.  The  lower  apparatus 
for  the  right  side  is  shown  in  Fig.  220,  that  on  the  left  side  being  similar.    The 

three  molar-band  stationary  anchorage  with  buccal 
and  lingual  root-wise  attachments  for  the  traction 
bars  to  the  cuspid,  was  constructed  to  offer  the  great- 
est possible  stationary  stability  so  that  all  the  space 
of  the  extracted  premolar  could  be  utilized  in  the 
bodily  tlistal  movement  of  the  cuspid.  But  even 
with  that,  it  was  found  necessary  later  to  extract  the 
second  premolar.  The  contour  apparatus  on  the  upper,  reinforced  with  the  disto- 
mesial  intermaxillarj^  elastics,  was  similar  to  that  shown  in  Fig.  210,  Chapter  XLII. 
This  apparatus  effected  a  bodily  labial  movement  of  the  incisors  and  a  mesial 
movement  of  the  cuspids  and  first  premolars  sufficient  to  open  spaces  between  the 


<e- 


FiG.  221. 


premolars  on  each  side  for  the  insertion  of  artificial  teeth,  the  advantages  of  which 
have  been  described.  The  upper  anchorages  also  aided  in  retruding  the  lower 
front  teeth.    The  final  result  is  shown  in  Fig.  221. 

Fig.  222  was  made  from  the  facial  and  dental  casts  of  a  miss  at  eleven  and 
thirteen  years  of  age,  which  illustrates  on  the  left  the  effect  of  a  combination  of 
the  local  cause  of  adenoids,  producing  a  retruded  upper;  with  that  of  heredity, 
producing  a  protruded  lower  denture  in  relation  to  a  normal  mandible.    The  decided 


CHAPTER  XLIV.     DIVISION  3.     CLASS   III 


315 


protruded  position  of  the  lower  front  teeth  in  relation  to  the  upper  gave  one  the 
impression  that  the  mandible  was  held  forward  of  the  normal  masticating  position. 
The  late  Dr.  Chas.  Butler,  who  saw  this  case  in  its  early  stages,  believed  this  to  be 
a  fact,  until  in  his  effort  to  make  her  close  her  lower  jaw  further  back,  she  suddenly 
forced  it  in  the  usual  functional  distance  forward  of  this. 

Fig.  222. 


Fig.  223. 


When  this  case  presented  for  treatment,  the  deciduous  lower  cu.spids  and  molars 
had  been  removed,  leaving  on  the  lower  jaw  only  the  fully  erupted  incisors  and 
first  permanent  molars  with  the  permanent  cuspids  just  commencing  to.  prick 
through  the  gums.      Fig.  223  partially  illustrates  the  lower  apparatus  that  was 

employed  in  this  case,  in  addition  to  the  apparatus 
on  the  upper  for  bodily  labial  movement  of  the  inci- 
sors. It  illustrates  the  principle  of  "sustained  anchor- 
ages" which  is  fully  defined  and  illustrated  in  Chapter 
XV.  This  was  demanded  because  of  the  necessity  of 
reinforcing  the  stability  of  single  molar  anchorages 
on  each  side.  The  lingual  arch-bow  resting  in  the 
incisor  hooks  easily  glides  into  the  long-bearing  tubes 
with  firmly  sustained  attachments  to  heavy  molar 
bands.  The  labial  arch-bow  No.  22  or  23  is  sustained 
on  the  incisors  by  open  tube  attachments  (not  shown  by  the  engraver).  It  can  be 
seen  that  the  lingual  force  exerted  by  this  bow  upon  the  incisors  cannot  possibly 
tip  the  molars  forward  or  rotate  them  on  account  of  the  long-bearing  lingual  tubes, 
so  long  as  the  bands  remain  firmly  cemented  to  the  teeth;  consequently,  if  the 
molars  move  at  all  it  must  be  a  bodily  movement,  which  means  that  their  stationary 
anchorage  stability  is  greatly  increased.     The  more  modern  root-wise  buccal  an- 


316  PART   VI.    DENTO-FACIAL  MALOCCLUSIONS 

chorage  tvibes  for  thr  rrtruding  arch-bow  increases  the  mechanical  advantage  by 
reducing  the  strain  of  the  band  attachments  to  the  molars,  as  the  force  would 
then  be  exerted  nearer  the  center  of  resistance  to  root  movements. 

It  will  be  seen  that  the  reaction  of  the  sustaining  power  of  the  lingual  arch- 
l)ow  on  the  molars  is  exerted  as  an  intrusive  force  upon  the  incisors,  which  in  this 
case  is  very  desirable.  In  the  preliminary  assembling  of  this  apparatus,  place  the 
incisor  bands  first,  and  then  place  the  molars  with  the  lingual  bow  in  the  tubes. 
See  that  the  bow  glides  easily  in  the  tubes  so  that  the  retrusive  movement  of  the 
incisors  with  the  intermaxillary  force  and  labial  traction  bow  is  not  obstructed. 

In  connection  with  the  retrusive  force  of  the  arch-bow  upon  the  incisors,  the 
disto-mesial  intermaxillary  force  is  an  important  auxiliary.  The  intermaxillary 
hooks  for  the  elastics — not  shown  in  the  engraving — can  always  be  easily  attached 
to  an  arch-bow,  as  explained  in  the  chapter  on  "technics." 


CHAPTER   XLV 

Division  4,  Class  III 

RETRUSION   OF  THE  UPPER  DENTURE   WITH   PROGNATHIC  MANDIBLE, 
COMMONLY  ACCOMPANIED   WITH   OPEN-BITE   MALOCCLUSION 

Fi°-  "'■^■*-  In  a  large  proportion  of  cases  which  are  denominat- 

ed prognathic  mandibles,  the  chin  is  in  perfect  esthetic 
relation  to  the  main  features  of  the  physiognomy, 
the  visual  error  being  due  to  the  immediate  relations 
of  a  pronounced  retruded  upper.  Real  prognathic 
mandibles,  however,  arising  purely  from  heredity  and 
rarely  from  local  causes  are  not  uncommon.  Prog- 
nathic mandibles  in  connection  with  normal  uppers, 
and  with  retruded  uppers,  may  arise  from  heredity, 
and  be  further  emphasized  by  local  causes.  The 
latter  is  well  illustrated  in  Fig.  205,  Chapter  XL. 

The  local  cause  which  produces  prognathism  of 
the  mandible  is  the  same  as  that  which  produces 
open-bite  malocclusion,  and  which  can  be  definitely 
traced  to  the  early  long  continued  habit  of  mouth- 
breathing,  which  may  arise  from  any  abnormal  inter- 
ference with  the  natural  freedom  of  the  nasal  air 
passages,  originating  mostly  from  adenoids  and 
continued  through  the  period  in  which  these  abnor- 
mal growths  exert  their  peculiar  local  and  systemic 
action. 

As  the  kind  of  open-bite  malocclusion  which  arises  from  this  cause  is  almost 
invariably  associated  with  prognathism  of  the  mandible,  it  has  been  deemed 
advisable,  for  teaching  purposes,  to  describe  this  malformation  in  detail  as  one  of 
the  important  characteristics  of  this  Division.  The  practical  treatment  of  other 
forms  of  open-bite  malocclusion  is  fully  described  under  Type  G,  Division  1, 
Class  I. 

In  papers  read  before  the  Odontological  Society  of  Chicago,  in  1894,  the  Ameri- 
can Institute  of  Dental  Pedagogics  in  1905,  and  the  National  Dental  Association 
in  1917,  the  author  expressed  in  substance  the  following  summary  in  regard  to  the 
modus  operandi  of  this  cause:  The  prodviction  of  open-bite  malocclusion  from 
early  mouth-breathing  is  due  to  long  continued  mechanical  forces  of  the  ligaments 
and  muscles,  mostly  during  sleep,  applied  to  the  developing  mandible  of  childhood 

317 


318 


I'ART    17.     DKXTO-FACfAL    MALOCCLUSIONS 


Fig.  225. 


at  a  time  when  the  cjuality  of  tlu'  hone  renders  it  pceuliarly  susceptible  of  being 
easily  deflected  from  the  form  of  its  natural  growth. 

When  the  jaws  are  widely  apart  during  the  long  sleeping  hours  of  childhood, 
tlie  mandible  under  the  strain  of  the  various  forces  is  similar  to  a  lever  of  the 
second  kind.    The  condyles  resting  in  their  sockets  are  the  fulcrum,  the  power  which 

forces  and  holds  the  jaws  open  is  the  hyoid  muscles  at- 
tached to  the  mandible  beneath  the  chin,  and  the  weight 
acting  in  the  other  direction  is  the.  masseter  and  in- 
ternal pterygoids  attached  at  the  angles  of  the  rami. 
Again,  when  the  jaws  are  widely  open,  the  condyles, 
with  the  intervening  interarticular  fibro  cartilages, 
are  pressed  against  the  posterior  inclined  planes  of  the 
articular  eminences  and,  under  the  strain  of  the  cap- 
sular ligaments,  tend  to  carry  them  back  into  their 
sockets  with  a  force  that  is  directly  communicated 
to  the  rami.  Both  these  influences  acting  upon  an 
undeveloped  mandible  during  the  early  years  of  its 
immaturity  in  form,  will  tend  to  straighten  it,  or  more 
correctly  speaking,  will  prevent  the  rami  from  fully 
assuming  their  natural  approach  to  right  angles  in 
relation  to  the  body  of  the  mandible. 

To  more  fully  illustrate  this  theory,  glance  at  Fig. 
225,  which  was  taken  from  Gray's  Anatomy,  and  is  intended  to  show  the  relative 
size  and  shape  of  the  mandible  at  birth,  puberty,  and  adult  development,  during 
which  time  the  relation  of  the  rami  to  the  body  changes  from  a  decidedly  obtuse 

to  nearly  a  right  angle. 

Fig.  226  is  made  from  one  of 
Dr.  Cryer's  illustrations  of  normal 
occlusion.  In  that  shown  on  the 
right,  the  mandibular  portion  of 
the  picture  was  removed,  cut  at 
the  angle,  and  replaced  in  the 
position  it  might  assume  during 
childhood  under  slight  continued 
force  exerted  in  the  direction  of 
the  arrows  by  the  muscles  while 
liolding  the  jaws  wide  apart. 

In  many  cases  of  open-bite 
malocclusion  caused  by  early  continued  mouth-breathing,  the  relations  of  the  rami 
and  body  may  be  seen,  from  a  profile  view  of  the  face,  to  stand  at  a  more  obtuse 
angle  than  is  normal,  and  with  the  frequent  production  of  prognathism;  both  of 
which  are  well  shown  in  Fig.  227,  which  illustrates  four  cases  in  practice  before 


Fig.  226. 


CHAPTER   XLV.     DIVISION   A.     CLASS   III 


319 


Fig.  227. 


1^^^ 

^fL 

ft 

a.',!flip' 

1^ 

' 

^1 

320 


PART    VI.     DE.\ TO-FACIAL   MAI.OCCLU.SIONS 


treatment.  The  dental  models  shown  below  the  faeial  easts  were  made  from 
impressions  taken  in  the  usual  manner  by  pressing  modeling-compound  against 
the  front  teeth,  with  the  mandible  in  its  most  posterior  position.  When  one  con- 
siders the  mechanism  of  the  cause,  it  will  be  seen  that  this  straightening  of  the  man- 
dible, while  not  inhibiting  its  growth  in  other  dimensions,  increases  the  distance 
from  the  point  of  the  chin  to  the  condyle,  with  a  protruding  movement  of  the  body 
of  the  mandible  and  its  contained  lower  denture.  Again,  when  one  remembers 
that  the  prime  cause  of  obstructed  nasal  breathing  and  its  resultant  open-bite 
malocclusion  is  adenoids,  which  in  themselves  are  the  prime  cause  of  inhibited  de- 

FiG.  228. 


velopment  of  the  maxilla,  and  which  result  in  the  common  upper  retrusions,  one  can 
then  appreciate  why  it  is  that  open-bite  malocclusions  are  so  frequently  found  in 
Class  III,  and  also  why,  in  so  many  of  these  cases,  the  mandible  appears  to  be  so 
decidedly  prognathic  in  relation  to  the  upper ,  but  which  no  doubt  is  partly  due  to  a 
visual  effect  in  comparing  the  immediate  relations  of  even  a  moderately  protruded 
lower  with  a  decidedly  retruded  upper — the  one  enhancing  in  appearance  the  dis- 
harmony of  the  other. 

In  three  of  these  cases,  as  in  many  others  of  the  same  pronounced  character, 
the  mandible  is  bent  appreciably  to  one  side,  as  shown  by  comparing  the  relations 
of  the  upper  and  lower  front  teeth.  This  condition  may  be  due  to  an  unevenness 
in  the  action  of  the  forces,  or  perhaps  what  is  more  probable,  as  mentioned  in  the 
chapter  on  Lateral  Malocclusion,  it  arises  when  the  mother,  either  from  thought- 
lessness or  possible  necessity,  causes  the  babe  to  lie  upon  one  side  far  more  than 


CHAPTER   XLV.     DIVISION  4.     CLASS  III  321 

upon  the  other,  which  in  itself  results  at  times  in  a  permanent  bending  of  the 
mandible  to  the  opposite  side.    See  Lateral  Malocclusion,  Chapter  XXVII. 

For  general  treatment  of  open-bite  malocclusion,  see  Chapter  XXVIII,  Divi- 
sion 1,  Class  I. 

Fig.  228  illustrates  a  pronounced  typical  case  of  this  Division,  of  a  girl  thirteen 
years  of  age,  which  the  author  is  pleased  to  present,  because  it  was  the  very  first 
case  in  orthodontia  in  which  a  bodily  protrusive  movement  of  the  front  teeth 
was  ever  attempted.  It  was  the  first  case  also  which  combined  as  an  auxiliary 
the  disto-mesial  intermaxillary  force.  It  was  first  published  in  a  paper  read  before 
the  Chicago  Dental  Society,  February  2,  1893,  and  illustrated  with  plaster  facial 
and  dental  casts,  as  shown,  and  the  original  apparatus  mounted  on  the  models  of 
the  case  and  set  up  on  an  articulator  to  show  the  reciprocal  action  of  the  inter- 
maxillary elastics  in  reinforcing  the  upper  anchorages  and  retruding  the  lower 
front  teeth.  It  was  later  presented  with  other  cases  at  the  International  Dental 
Congress,  August,  1893,  in  which  the  same  character  of  forces  had  been  employed. 

The  retruded  upper  was  caused  principally  through  the  inhibited  development 
of  the  maxilla  which  contracted  the  entire  upper  arch  with  the  production  of  a  high 
and  narrow  dome,  so  contracted  indeed,  that  the  patient  was  often  obliged  to  dis- 
lodge food  from  it  with  her  finger.  The  injudicious  extraction  of  a  lateral  incisor, 
by  her  home  dentist,  to  permit  the  right  upper  cuspid  to  erupt,  increased  the  dif- 
ficulties of  correcting  the  upper  retrusion. 

The  open-bite  malocclusion  due  to  long  continued  early  mouth-breathing,  which 
straightened  the  form  of  the  mandible,  was  caused  by  the  same  adenoid  growths 
whose  influence  contracted  and  retruded  the  upper. 

The  fact  that  the  chin  in  the  finished  facial  cast  is  not  protruded,  while  in  the 
beginning  facial  cast  the  lower  lip  is  quite  decidedly  protruded  in  relation  to  the 
chin,  indicates  that  the  case  in  this  particular  was  similar  to  those  in  Division  3  of 
this  Class.  Again,  the  contracted  and  retruded  upper  resulting  from  local  causes, 
is  similar  in  this  particular  to  Division  2  of  this  Class. 

Attention  is  called  to  these  fine  points  of  dento-facial  relations  for  the  purpose 
of  training  the  minds  of  students  in  the  principles  of  diagnosis. 

Fig.  229  illustrates  an  extreme  type  of  this  Division,  and  the  difterent  stages  of 
correction.  It  will  be  seen  that  the  required  bodily  movement  of  the  upper  front 
teeth  to  correct  the  facial  outlines,  opened  spaces  for  the  insertion  of  one  artificial 
tooth  on  the  right  side  and  two  on  the  left.  The  prosthodontia  work  completing 
the  case,  as  shown  by  the  dental  casts  on  the  right,  was  performed  by  Dr.  Hart 
J.  Goslee. 

One  of  the  surprising  conditions  of  this  case  when  it  presented  for  treatment, 
was  an  artificial  extra  right  lower  lateral  attached  to  a  slipper  crown  on  the  cuspid, 
which  is  not  distinctly  shown  by  the  picture.  This  peculiarity  is  worthy  of  mention 
at  this  time,  because  it  is  one  of  the  many  instances  which  proves  what  has  been 
mentioned  elsewhere,  i.  e.,  that  the  mandible  and  other  bones  which  characterize 


322 


PARI     17.     DE.\  lO-l-AClM.    M  AlAKLLLSlOXS 


the  human  physiognc^my  do  not  always  show  inherited  disharmonies  of  size  and 
form  in  relation  to  adjoining  bones,  until  sometime  after  the  beginning  of  adoles- 
cence. Nor  are  pronounced  inherited  peculiarities  and  characteristics  which  per- 
tain to  the  entire  body,  indicated  at  times  in  a  slight  degree,  until  after  thirteen 
or  fourteen  years  of  age. 

The  rapid  growth  of  the  mandible,  in  this  case,  in  response  to  the  forces  of 
heredity  after  the  eruption  of  nearly  all  the  teeth,  opened  spaces  between  the 
front  teetli,  notwithstanding  their  decided  lingual  inclination.  The  family  dentist 
who  had  the  case  in  charge,  knowing  of  no  other  way  to  close  these  spaces,  inserted 

Fk;.  229. 


the  artificial  tooth.  The  removal  of  this  tooth  permitted  a  lingual  movement  of 
the  roots  of  the  incisor  teeth,  placing  them  in  a  more  upright  position.  At  the  same 
time,  the  extruding  movement,  with  the  occipital  force,  corrected  the  open-bite 
malocclusion. 

The  two  following  cases,  which  are  quite  typical  of  this  Division,  were  presented 
with  a  paper  read  before  the  National  Dental  Association  in  1917,  mainly  to 
show  the  possible  rapidity  of  an  extrusive  bodily  movement,  with  the  correction 
of  open -bite  malocclusion  for  patients  beyond  the  age  of  adolescence.  The  follow- 
ing is  from  the  published  proceedings  of  that  meeting: 

"Fig.  230  shows  the  casts  of  a  young  man  twenty-one  years  of  age  for  whom  the 
operation  for  correction  was  commenced.  May,  1910,  and  ended,  as  shown,  May, 
1911.  The  mandible  in  this  case  was  bent  to  the  right  carrying  its  left  body  and 
buccal  teeth  far  forward  of  their  normal  position,  which  in  connection  with  the 
retruded  upper,  placed  the  lower  left  buccal  teeth,  in  a  closure  of  the  jaws,  fully 


CHAPTER   XLV.     DIVISION 


CLASS   III 


323 


the  width  of  two  premolars  in  mesial  malrelation  to  the  uppers ;  while  on  the  right 
side,  the  disto-mesial  malrelation  was  hardly  the  width  of  a  single  premolar.  The 
early  loss  of  the  first  lower  molar  on  the  right  side,  however,  had  permitted  the 
second  and  third  molars  to  drift  forward  and  thus  diminish  to  that  extent  the  orig- 
inal occlusal  malrelations  of  these  teeth.     On  the  upper  left  side,  the  loss  of  the 

Fig.  2.30. 


crown  of  the  first  molar  allowed  the  third  molar  to  close  into  this  space,  and  thus 
decrease  to  that  extent  the  original  open-bite. 

"The  treatment  consisted  first  in  the  extraction  of  the  first  left  lower  molar, 
the  latter  being  chosen  in  this  case  because  it  contained  a  large  amalgam  filling,  and 
probably  a  devitalized  pulp.  This  was  followed  with  a  bodily  retruding  movement 
of  the  lower  premolar  and  labial  teeth,  more  upon  the  left  side  than  on  the  right, 
and  with  the  usual  care,  with  special  apparatus,  to  close  the  buccal  spaces  by 
a  bodily  disto-mesial  movement.     Nothing  is  so  conducive  to  irritation  as  in- 


324 


PART    VI.     DEMO-FACIAL   MALOCCLUSIONS 


verted  V-shaped  spaces  between  buccal  teeth ,  following  the  extraction  of  molars 
or  premolars,  or  attempts  at  extensive  regulation  with  single  molar  anchorages 
permitting  inclination  movement,  and  destruction  of  perfect  masticating  occlusion. 
This  movement  of  the  lower,  in  connection  with  the  upper  i.)odily  labial  movement, 
and  the  artificial  closure  of  the  upper  first  molar  space,  resulted  in  ([uite  a  perfect 

Fig.  231. 


masticating  occlusion,  and  a  remarkable  improvement  in  the  physiognomy,  which, 
the  final  plaster  cast  inadequately  portrays. 

"In  Fig.  231  is  shown  the  plaster  casts  of  a  man  twenty-four  years  of  age, 
a  graduate  of  the  University  of  Michigan,  who  has  recently  finished  a  special  post- 
graduate course  at  the  University  of  Chicago,  and  has  now  entered  the  law  depart- 
ment of  that  school.  He  is  six  feet  tall,  of  robust  figure  and  apparent  rugged  health. 
This  perfect  mental  and  physical  condition  is  mentioned,  because  it  is  remarkable 
in  view  of  the  fact  that  early  untreated  adenoids  and  long  continued  mouth- 


CHAPTER  XLV.     DIVISION  4.     CLASS  III  325 

breathing  inhibited  the  development  of  the  maxilla  and  caused  a  malformation 
of  the  mandible  and  an  open-bite  malocclusion,  which  permitted  a  very  imperfect 
masticating  closure  upon  only  the  disto-occlusal  borders  of  the  second  lower 
molars,  so  that  during  all  his  life  from  early  childhood  he  had  hardly  been  able 
to  approach  the  mastication  of  food. 

"The  treatment  in  this  case  was  commenced  October  4,  1916 — the  casts  of 
which  are  shown  on  the  left.  Those  on  the  right  were  made  about  one  year  later 
when  the  correction  was  about  two-thirds  completed.  They  were  made  at  that  time 
to  aid  in  the  illustration  of  a  paper  read  before  the  October,  1917,  meeting  of  the 
National  Dental  Society.  The  principal  treatment  consisted  in  a  bodily  labial 
movement  of  the  upper  front  teeth,  and  a  retrvisive  and  extrusive  movement  of  the 
lower  labial  teeth  and  premolars. 

"The  difhculties  on  the  lower  were  increased  by  the  loss  of  the  first  permanent 
molars  which  were  extracted  at  about  twelve  years  of  age.  This  permitted  the 
second  molars  to  tip  forward  to  a  decided  mesial  inclination.  The  treatment  here 
consisted  in  shifting  the  back  teeth  to  proper  occlusal  relations,  and  then,  by  grind- 
ing their  occluding  surfaces,  to  partially  close  the  open -bite.  The  occluding  position 
of  the  original  dentures,  shown  on  the  left,  was  placed  by  Dr.  Hart  J.  Goslee  in 
exact  duplication  of  the  beginning  labial  bite  model. 

"The  entire  distal,  lingual,  and  extrusive  movement  of  the  lower  was  accom- 
plished with  the  intermaxillary  and  occipital  forces.  The  case  was  finished  with  a 
perfect  interdigitating  occlusion  of  the  premolars,  and  with  the  first  molar  spaces 
supplied  with  artificial  teeth,  enabling  him  for  the  first  time  in  his  life  to  perfectly 
masticate  his  food. 

"About  two  weeks  before  the  meeting,  the  apparatus  was  removed  and  the 
impressions  taken  for  the  dental  and  facial  casts  shown  on  the  right.  He  is  now 
wearing  a  six-band  retainer  on  the  lower  front  teeth  which  carries  the  intermaxillary 
hooks  for  retaining  elastics  to  the  upper,  as  is  usual  in  such  cases." 

It  is  a  great  pleasure  to  publish  in  this  connection  the  following  words  of  Dr. 
Goslee,  who  discussed  this  paper,  and  who  was  intimately  in  touch  with  the  treat- 
ment of  these  and  other  almost  unbelievable  corrections  in  the  author's  practice. 

Dr.  Hart  J.  Goslee,  Chicago:  "I  have  no  desire  to  take  up  your  time  at  this 
late  hour,  but  I  would  be  very  remiss  if  I  did  not  take  occasion  to  say  to  the  mem- 
bers of  this  Section  that  I  have  seen  all  these  cases.  I  do  not  say  this  to  imply  in  any 
way  that  Dr.  Case's  word  is  not  sufficient,  but  I  have  been  very  closely  asso- 
ciated with  Dr.  Case  in  much  of  his  work,  and  wish  to  add  my  testimony  as  to  his 
success  in  treating  these  difficult  cases  of  malocclusion.  I  have  been  watching  his 
work  for  twenty  years  and  the  results  that  he  has  produced  in  one  year  in  some  of 
these  cases  are  wonderful,  indeed  they  are  nothing  less  than  marvelous.  And  par- 
ticularly is  this  true  of  the  case  of  the  young  man  to  which  he  has  referred  so 
extensively,  and  which  case  I  have  observed  closely  since  the  beginning." 


PART  VII 


Practical  Treatment  of  Unclassified  Malocclusions 


UNCLASSIFIED  MALOCCLUSIONS 
TABLE  OF  CHARACTERS 


Infra  and  Supra-Occlusions 
Crowded  Malalignments 
Malturned  Teeth 
Narrow  and  Wide  Arches 
Abnormal  Interproximate  Spaces 
Impacted  Teeth  and  Their  Treatment 


UNCLASSIFIED  MALOCCLUSIONS 


Foreword 

There  are  certain  distinctive  characters  of  irregularity  of  the  teeth  all  of  which 
arise  from  local  causes,  and  therefore  will  be  found  in  each  one  of  the  three  classes 
of  buccal  occlusion,  often  dominating  the  character  with  which  they  are  found. 
For  this  reason  they  cannot  be  regarded  as  divisions  or  types  peculiar  to  any  one 
class. 

For  purposes  of  teaching,  however,  certain  dento-facial  characters  which 
belong  to  this  group  of  locally  caused  malpositions  are  placed  and  described  under 
Division  1  of  Class  I,  where  they  may  be  intelligently  compared  with  other  dento- 
facial  malocclusions  with  which  they  frequently  become  identified. 

By  referring  to  the  "Table  of  Characters"  on  the  opposite  page,  it  will  be 
seen  that  each  one  of  the  characters  which  compose  the  group  now  under  considera- 
tion, is  susceptible  of  assuming  a  variety  of  malpositions  which  may  decidedly  differ 
in  degree  and  demands  of  treatment. 

In  order  to  give  the  student  a  clear  understanding  of  the  most  effective  methods 
which  are  employed  for  their  correction,  the  most  common  malpositions  of  each 
character  are  grouped  and  treated  under  their  respective  heads.  And  though  illus- 
trated and  described  as  applicable  to  only  this  irregularity,  the  same  methods  and 
principles  of  force  m.ay  be  employed  wherever  these  malpositions  arise  in  connec- 
tion with  other  characters,  or  in  different  classes  of  malocclusion. 

The  drawings  are  designed  to  conspicuously  show:  first,  the  malposition  of 
the  character  under  consideration,  and  every  necessary  view  of  the  apparatus  in 
position  on  the  teeth,  and  with  special  parts  in  detail;  second,  the  apparatus 
disassembled  from  the  teeth  and  shown  in  its  various  parts,  the  whole  calculated 
to  render  every  aid  for  its  correct  construction.  With  this  mainly  in  view,  there 
has  been  no  attempt  at  anatomic  or  artistic  effect,  the  principal  object  being  to 
distinctly  show  the  character  of  the  irregularity  and  the  appliances,  or  the  complete 
apparatus  which  the  author  has  successfully  used  in  his  practice  for  its  correction. 

Accompanying  the  illustrations  will  be  found  a  concise  description  of  the 
character  of  the  irregularity  treated,  the  movement  demanded  for  its  correction, 
the  apparatus  in  detail,  with  the  gauge  sizes  of  its  several  parts,  the  special  force  it 
is  calculated  to  exert,  methods  of  construction,  assembling,  adjustment,  etc. 


320 


CHAPTER  XLVI 
INFRA  AND   SUPRA-OCCLUSION 

When  one  or  more  teeth  are  above  or  below  the  normal  oeelusal  plane,  they 
are  in  the  malposition  of  Infra  or  Supra-occlusion.  If,  however,  one  or  the  other 
of  these  conditions  involves  all  the  front  teeth,  they  are  then  in  the  malposition 
of  open-bite,  or  close-bite  malocclusion. 

For  all  the  ordinary  cases  of  infra  or  supra-occlusion  of  one  or  more  teeth, 
for  patients  under  twelve  or  fourteen  years  of  age,  as  in  all  cases  of  simple  mal- 
alignments and  maltumed  teeth,  the  "Midget  Apparatus,"  described  in  Chapter 
XX.  is  now  almost  solely  employed  by  the  author. 


Fig.  232. 


Infra-Occlusion  of  Cuspids 

The  apparatus  shown  in  Fig.  232  is 
intended  for  the  correction  of  a  very 
common  form  of  irregularity  which  may 
be  considered  the  simplest  of  that  most 
common  malposition  which  is  character- 
ized by  maleruption  of  the  cuspids.  It  is 
placed  in  this  group  because  a  simple 
resilient  alignment  bow  No.  23,  as  shown, 
will  commonly  correct  it  with  little  atten- 
tion. The  effort  of  nature  to  erupt  crowded 
cuspids,  v/ill  at  times  extrude  the  centrals. 
Should  all  of  the  incisors  demand  a  slight 
labial  movement  to  enlarge  the  arch  and 
give  more  room  for  the  cuspids,  the  lat- 
erals can  also  be  banded  with  open-tube, 
or  small  hook  attachments.  If  this  con- 
dition is  somewhat  marked,  it  may  be 
necessary  to  use  an  expansion  arch-bow 
threaded  for  nuts  at  the  mesial  ends  of 
the  molar  tubes.  Again,  if  the  premolars 
have  been  forced  into  lingual  malalign- 
ment, or  if  the  premolar  area  demands  a  slight  expansion,  additional  appliances 
will  be  indicated. 

This  apparatus  is  applicable  only  to  those  cases  in  which  the  cuspids  demand 
slight  movement  and  little  artificial  aid.     For  the  application  of  greater  force,  see 

331 


332 


PART    VII.     UNCLASSIFIED  MALOCCLUSIONS 


Class  I.  In  this  connection,  it  should  always  be  rcnu'inhiTcd  that  in  the  common 
course  of  secondary  dentition,  the  cuspids  are  often  naturally  crowded  out  of  their 
normal  alignment,  and  when  the  direct  cause  of  this  amounts  to  no  more  than  a 
slight  constriction  of  the  space  required,  nature  will  usually  correct  the  malposition 
for  young  patients  by  the  natural  growth  of  the  jaw. 


Fig.  233. 


INFRA-OCCLOSION   OF   UPPER   INCISORS 

Fig.  233  is  intended  to  illustrate  a  simple 
form  of  open -bite  malocclusion  which  pertains 
only  to  the  incisor  area,  and  which  may  be 
very  easily  corrected  for  young  patients,  with 
a  simple  resilient  alignment  arch-bow  No.  23 
or  24  (.022"  or  .020").  The  ends  of  the  bow 
are  placed  in  the  anchorage  tube  attachments 
on  the  molars,  and  the  bow  is  then  sprung  into 
position  under  the  cuspid  hook  attachments 
and  over  those  on  the  incisors. 

It  must  be  remembered  before  placing  any 
small  resilient  arch-bow  on  the  teeth,  that  it 
should  be  curved  by  drawing  it  over  the  ball 
of  the  thumb  until  its  ends  nearly  touch,  else 
it  is  liable  to  exert  a  buccal  expanding  force 
on  the  molars.  If  a  lateral  expansion  of  the 
arch  is  demanded,  distributing  lingual  exten- 
sions made  of  half-round  hook  wire  should  be 
soldered  to  the  lingual  surfaces  of  the  molar 
bands  to  rest  upon  and  fit  the  lingual  surfaces 
of  adjoining  teeth,  and  then  the  uncurved  or 
straight  arch-bow  may  be  sprung  into  its  anchorage  tubes  to  act  as  an  expander, 
according  to  the  potential  force  that  is  given  it. 

If  one  or  more  of  the  teeth  are  malturned,  the  bands  should  carry  the  proper 
attachments  for  rotating  them.  When  the  cuspids  are  in  normal  occlusal  position, 
if  used  as  fulcrums,  this  force  will  abnormally  intrude  them,  in  which  case  rubber 
bands,  extending  from  the  upper  teeth  to  a  bow  attached  to  the  lower,  may  be  in- 
dicated, or  the  force  upon  the  cuspids  may  be  relieved  by  distributing  it  to  the 
premolars. 


CHAPTER   XL\II 
CROWDED   MALALIGNMENTS 

When  one  or  more  teeth  occlude  hngually,  labially,  or  buccally  to  the  normal 
line  of  the  arch,  they  are  in  malposition  or  malalignment. 

Commonly,  the  teeth  are  so  crowded  in  the  arch  that  the  malaligned  teeth 
cannot  regain  their  normal  pose  without  the  aid  of  artificial  force.  When  a  dental 
arch — especially  the  upper — is  deprived  of  its  natural  arch  support  through  the 
loss  or  maleruption  or  malalignment  of  one  or  more  labial  teeth,  the  influences  of 
muscular  action  alone  will  tend  to  contract  its  natural  boundaries.  The  contraction 
of  a  dental  arch  in  this  manner  will  often  cause  the  opposing  arch  to  also  become 
contracted,  and  the  incisors  malposed  through  the  forceful  influences  of  occlusion 
and  muscular  action. 

The  origin  of  a  large  proportion  of  all  complex  irregularities,  be  they  simple 
or  complicated,  may  be  traced  to  the  premature  loss — usually  from  extraction — 
of  the  temporary  teeth,  followed  by  a  maleruption  of  the  succeeding  teeth. 

It  would  seem  hardly  possible,  though  true,  that  the  contracting  action  of  the 
muscles  of  lips  and  cheeks  could  increase  a  complicated  irregularity  which  may  have 
started  from  the  maleruption,  injudicious  extraction,  or  careless  loss  of  a  single  tooth. 

In  the  contemplation  of  correction,  with  a  view  to  permanent  retention,  the 
teeth  of  the  opposing  jaw,  therefore,  will  frequently  require  regulating  to  readjust 
the  occlusion.  In  the  preliminary  examination  and  diagnosis  of  the  more  com- 
plicated cases,  the  character  of  occlusion  of  the  first  permanent  molars  is  of  the 
greatest  importance.  And  in  all  cases  where  there  is  no  decided  protrusion  of  one 
denture  or  the  other,  demanding  the  extraction  of  premolars,  the  teeth  should  be 
invariably  placed  in  iioniial  occlusion.  The  apparatus  should  therefore  be  con- 
structed for  the  application  of  forces  which  will  not  only  laterally  expand  the  arch 
or  arches  to  normal  bucco-Iingual  relations,  but  also  to  normal  disto-mesial 
relations. 

In  malalignments  of  the  upper,  the  mesio-buccal  cusps  of  the  first  upper  molars 
will  commonly  be  found  riding  too  much  upon  the  mesio-buccal  cusps  of  the  first 
lower  molars,  instead  of  closing  evenly  in  the  sulci  between  the  two  lower  cusps 
and  overlapping  them  bucally,  as  they  should.  It  will  be  observed  that  this  for- 
ward shifting  of  the  upper  molars,  which  is  commonly  started  by  the  premature 
loss  of  deciduous  teeth,  will  tend  through  occlusal  forces,  to  drive  the  lower  molars 
forward,  and  produce  either  a  malalignment  of  the  lower  teeth,  or  a  proportionate 
protrusion  of  the  entire  denture.  Too  much  stress,  therefore,  cannot  be  laid  upon 
the  advisability  of  intelligently  determining  the  effect  which  the  teeth  are  destined 

333 


334 


PART   VII.     UNCLASSIFIED   MALOCCLUSIONS 


Fig.  23S 


Fig.  234.  to  h.'ivc  upoii  the  facial  uutlincs,  and  in 

(k'cidini,^  whether  the  occipital  or  the  inter- 
maxillary force  is  the  more  applicable  for 
correcting  the  occlu.sal  malrelations. 

If  the  mesial  malocclusion  of  the  upper 
molars  is  greater  than  will  be  possible  to 
correct  by  a  slight  distal  movement,  which 
may  be  brought  about  by  a  reaction  of  the 
alignment  forces  of  the  upper  apparatus, 
provision  should  be  made  for  the  applica- 
tion of  the  intermaxillary  force,  bearing  in 
mind  that  the  reciprocal  action  of  this  force 
will  tend  toward  a  mesial  movement  of  the 
lower.  If  this  is  not  advisable,  it  should 
be  prevented.  (See  chapter  on  the  appli- 
cation of  the  intermaxillary  force. )  It  may 
be  that  only  the  occipital  force  should  be 
employed  as  an  auxiliary. 

F'or  nearly  all  the  ordinary  crowded 
malalignments  for  children,  including 
supra  and  infra-occlusions,  the  midget  sizes  of 
arch -bows  Nos.  24,  25,  and  26,  will  be  found 
effective.  For  youths  and  even  older  pa- 
tients, when  the  malalignment  is  slight  and 
somewhat  similar  to  the  position  shown  in 
Fig.  234,  a  resilient  alignment  arch-bow  No. 
22  will  usually  correct  the  irregularity  with 
the  requirement  of  few,  if  any,  subsequent 
adjustments.  After  the  bands  are  cemented, 
curve  the  bow  over  the  ball  of  the  thumb 
to  the  form  of  the  arch,  and  place  it  in  the 
molar  tubes  and  cuspid  rests  and  then  spring 
it  into  its  attachments  on  the  contruded 
teeth,  bending  the  hooks  closely  against  the 
teeth. 

When  there  is  a  greater  lingual  malalign- 
ment of  one  or  more  teeth,  it  may  not  be  pos- 
sible or  advisable  to  force  the  arch-bow  to 
immediate  contact  with  the  tooth  in  the  clasp 
of  an  open  tube  or  ordinary  hook  attachment, 
in  which  case  it  may  at  first  be  attached  to  the  bow  with  a  wire  ligature,  or  the 
midget  finger  spurs,  which  are  fully  described  in  Chapter  XIX. 


CHAPTER  XLVII.    CROWDED  MALALIGNMENTS 


335 


Fig.  236. 


Fig.  237. 


The  space  for  the  lower  incisors  is  freciuently  crowded  in  upon  by  the  contrusion 
of  the  cuspids,  caused  tisually  by  occlusion,  and  requiring  the  concurrent  regulation 
of  the  opposing  teeth.  Fig.  235  shows  the  application  of  a  small  pinrest  jack  No. 
19  attached  to  cuspid  bands  for  expanding  the  labial  arch.  It  also  shows  how  to 
place  the  jack  in  case  one  or  both  teeth  are  malturned  and  recjuire  rotating. 

The  lingual  jack  as  shown,  is  advisable  only  when  the 
cuspids  are  in  decided  lingual  malalignment.  Ordinarily,  the 
case  may  be  easily  corrected  for  young  patients  with  a  No.  20 
or  22  expanding  arch-bow  with  the  nuts  at  the  mesial  ends  of 
the  molar  anchorage  tubes,  communicating  with  strong  labial 
open-tube  attachments  on  the  front  teeth,  and  with  pin-head 
lingual  attachments  on  maltunied  teeth  for  rotating  with  wire 
ligatures. 

When  all  the  incisors  are  in  lingual  malalignment,  they 
can  frequently  be  easily  corrected  by  lacing  them  to  the  arch-bow  with  a  single 
election  ring,  as  diagrammatically  shown  in  Fig.  236. 

In  all  cases  over  twelve  years  of  age 
where  the  arch  is  contracted,  accom- 
panied with  malposition  of  the  incisors, 
it  will  demand  a  lateral  expansion  in 
order  to  place  the  teeth  in  alignment; 
moreover,  this  movement  of  one  denture 
will  often  demand  the  concomitant  ex- 
pansion of  the  other,  else  the  uncor- 
rected arch  will  force  the  other  back  to 
its  former  fixed  occlusion. 

Fig.  237  shows  a  common  method 
of  expanding  the  anterior  arch  as  an 
auxiliary  to  the  labial  or  lingual  curved 
push  bars.  The  lingual  bars  No.  18  for 
distributing  the  expanding  force  are 
threaded  at  their  extreme  mesial  ends 
to  screw  into  short  threaded  lingual 
tube  attachments  on  the  cuspids,  or 
they  may  be  soft-soldered.  The  prin- 
cipal object  of  this  method  of  attach- 
ment is  to  preserve  the  rigidity  of  the 
bars,  which  would  not  be  possible  if 
hard-soldered  directly  to  the  bands. 
The  distributing  bars  are  bent  to  pass  the  premolars  and  to  afford  means  of  attach- 
ment to  the  bar-rest  expanding  jack.  Their  distal  ends  rest  in  seamless  or  open-tube 
attachments  on  the  molars,  or  they  may  be  threaded  to  act  as  pull  or  push  bars  with 


336 


PART    VII.     UNCLASSIFIED  MALOCCLUSIONS 


nuts  respectively  distal  or  mesial  to  the  molar  tubes.  Tlie  l)uccal  molar  tubes  and 
cuspid  open-tube  attachments  provide  means  for  an  alignment  arch-bow  if  needed. 
If  the  lingual  cuspid  attachments  are  placed  at  the  extreme  gingival  borders,  the 
straight  jack  will  lie  close  to  the  lingual  incisal  ridge,  and  will  thus  not  materially 
interfere  with  the  tongue.  When  necessary  to  place  the  jack  further  back,  the  arc 
jack  will  be  found  preferable.     The  lingual  appliance  for  opening  space  for  the 


Fio.  238. 


Fi<;.  239. 


incisor  is  obsolete.     When  the  labial  arch  is  properly  expanded,  the  incisors  can 
be  usually  aligned  by  very  simple  methods. 

In  those  cases  where  the  dental  arches  are  not  complicated  with  a  variety 
of  malpositions,  the  apparatus  may  be  simplified  as  shown  in  Fig.  238,  which  does 
away  with  the  need  of  the  special  labial  appliances.  The  No.  18  distributing  bars 
attached  to  the  incisors  rest  in  open-tube  cuspid  and  molar  attachments.  Again, 
in  those  cases  where  the  front  teeth  are  not  greatly  malposed,  they  can  usually  be 
brought  to  alignment  by  the  aid  of  an  alignment  bow  with  ligatures,  etc.,  after  the 
arches  have  been  sufficiently  expanded  with  the  expanding  appliance.  In  all  cases 
of  malalignments  with  crowded  arches,  the  foundation  principle  of  correction  lies 
in  first  making  room  for  the  malposed  teeth  in  the  arch,  after  which  the  rest  of  the 
operation  is  comparatively  easy. 


CHAPTER   XLVII.     CROWDED  MALALIGNMENTS 


337 


Fig.  240. 


Drop  Jack. — In  the  irregvilarity  shown  in  Fig.  239,  the  right  premolars  and 
lateral  incisor  are  in  decided  lingual  malalignment,  in  consequence  of  which  the 
entire  arch  on  the  right  side  is  contracted.  The  left  lingual  distributing  bar  No.  18 
is  attached  to  the  right  central  for  the  purpose  of  carrying  all  of  the  teeth  within 
its  grasp  to  the  left.  In  the  combination  with  the  right  bar  No.  18,  the  distally 
reacting  force  from  the  lateral  incisor  can  be  received  either  upon  the  premolar  or 
the  molar,  it  being  desired  to  retrude  these  teeth  to  open  the  space  for  the  cuspid 
in  the  general  enlargement  of  the  arch,  and  correct  the  occlusion.  The  premolar 
attachment  is  peculiarly  adapted  for  producing  the  greatest  amount  of  inclination 
movement  in  proportion  to  the  force  exerted.  It  will  be  seen  also  in  this  combina- 
tion, that  the  distal  force  may  be  transferred  at  any  time  from  the  premolar  to  the 
molar.  With  this  apparatus  is  introduced  the  drop  expanding  jack,  which  is  es- 
pecially valuable  in  the  lateral  expansion  of  the  upper  arch,  where  interference  with 
the  tongue  should  be  relieved  as  much  as  possible. 

Occasionally  one  or  two  front  upper  teeth  are  inlocked  in  occlusion  back  of 
the  lowers,  demanding  considerable  force  to  move  them  to  alignment  for  patients 
older  than  twelve  years.  In  many  cases,  nothing  short  of  the  positive  force  of  a 
screw  jack  or  lingual  push-bow  will  accomplish  the  work. 

For  the  younger  class  of  patients,  the 
methods  shown  in  Fig.  240  will  be  found 
effective.  On  the  right  lateral,  the  liga- 
ture wire  is  passed  around  the  tooth  in 
the  form  of  a  double  loop  and  fastened  to 
the  bow  at  the  ends  of  a  thin  curved  tube 
which  is  slipped  on  the  bow  before  it  is 
placed.  The  curved  tube,  shown  in  the 
illustration,  lies  between  the  points  of 
attachment  of  the  wire.  The  length  of 
the  tube  can  be  gauged  so  that  the  wire 
will  exert  an  expanding  force  upon  the 
adjoining  teeth  to  make  room  for  the 
lateral. 

The  Matteson  attachment  on  the  left 
lateral  consists  of  a  strip  of  No.  28  or  30 
plate,  cut  as  shown,  and  soldered  to  the 
labial  face  of  the  band.    The  end  is  lapped 
over  the  bow  and  rolled  in  under  with  the 
pliers.    The  force  is  increased  from  time 
to  time  by  rolling  it  up  on  the  bow. 
Both  of  these  methods,  however,  give  far  more  pain  in  their  treatment  adjust- 
ments than  the  positive  force  of  a  screw,  which  is  always  sure,  comparatively  pain- 
less, and  therefore  to  be  preferred  in  the  alignment  of  all  extensive  contrusions,  and 


338  PART    17/.     LWCLASSIFIKD   MALOCCLUSIONS 

especially  for  inlocked  upper  incisors.  The  size  of  the  arch-bow  may  be  from  Nos. 
22  to  19,  according  to  the  age  of  the  patient  and  need  of  arch  expanding  force. 
In  the  employment  of  the  small  sizes  of  spring  arch-bows,  the  resilient  force  of  the 
bow  is  always  an  advantage,  and  preferable  for  young  patients  where  no  particular 
expansion  of  the  arch  is  required. 

The  double  mesial  and  distal  nuts  at  the  molars  are  frequently  of  advantage  for 
expansion  arch-bows.  They  lock  the  bow  firmly  in  position,  and  permit  a  movement 
of  it  in  either  direction  by  unscrewing  one  nut  and  screwing  up  the  other.  It  should 
be  remembered,  however,  that  this  locking  of  a  tooth  to  a  heavy  arch-bow  increases 
its  immovability,  and  establishes  to  that  extent  a  stationary  anchorage  quality. 
Therefore,  in  all  instances  when  a  distal  movement  of  the  buccal  teeth  is  desired 
for  the  correction  of  the  occlusion,  a  small  sized  arch-bow  instead  of  a  large  one  is 
chosen  for  the  bow  to  hold  the  teeth  in  aUgnment,  because  it  answers  every  purpose, 
and  yields  readily  to  an  inclination  movement  of  the  molars.  This  principle  should 
always  be  taken  advantage  of  in  the  application  of  the  disto-mesial  action  of  the 
intermaxillary  force.  Moreover,  this  is  one  of  the  principal  reasons  why  it  is  more 
scientific  and  effective  to  apply  this  force  distally  to  the  molars  through  the  medium 
of  sliding  tubes  and  intermaxillary  hooks  which  glide  upon  a  small  resilient  arch- 
bow,  than  through  the  medium  of  a  heavy  arch-bow  to  which  the  intermaxillary 
hooks  are  immovably  attached. 


CHAPTER  XLVIII 

MALTURNED  TEETH 

One  of  the  most  common  malpositions  is  that  of  malturned  teeth.  During 
the  process  of  erviption,  the  front  teeth  are  commonly  obliged  to  crowd  their  way 
into  the  arch  between  deciduous  or  permanent  teeth,  unless  deflected  completely 
out  of  alignment.  In  so  doing,  they  are  naturally  malturned  by  the  deflecting 
influence  of  their  broad  and  somewhat  thin  incisal  borders  coming  in  contact  with 
adjoining  teeth.  Later,  through  the  influence  of  natural  growth  of  the  jaws,  and 
muscular  action  favored  by  the  anatomic  shapes  of  the  roots,  they  commonly 
assume  a  normal  pose.  Where  the  alveolar  arches  do  not  sufficiently  enlarge  by 
growth,  and  where  teeth  are  otherwise  prevented  from  assuming  their  normal  pose 
through  the  forces  of  malocckision,  they  become  permanently  fixed,  and  so  remain 
malturned  and  often  overlapping  until  corrected  by  artificial  means. 

In  the  correction  of  malturned  teeth,  the  most  important  principle  to  be  re- 
membered is  that  mechanical  advantage  is  increased  in  proportion  to  the  distance 
from  the  central  axis  of  the  tooth  at  which  the  force  is  applied.  Therefore,  for  the 
rotation  of  the  labial  teeth,  the  force  should  be  applied  at  or  near  the  gingival 
border.     See  Rotating  Movement  in  Principles  of  Mechanics,  Chapter  XIII. 

As  stated  in  other  parts  of  this  work,  the  author  does  not  attempt  to  give  every 
variety  of  irregularity  and  complication  that  may  arise  in  practice,  but  only 
some  of  the  common  forms  of  malposition  for  the  purpose  alone  of  showing  practical 
methods  of  correction,  and  principally  the  application  of  implements  and  appli- 
ances which  any  ingenious  mind  will  be  able  to  modify  to  suit  the  case  in  hand.  The 
special  force  exerted  by  different  methods  will  be  briefly  described  with  the  appliance. 

For  the  rotation  of  children's  teeth,  nothing  can  be  employed  that  is  more 
effective  and  that  requires  less  treatment  adjustments  than  that  which  obtains  its 
motive  force  from  the  resiliency  of  very  light  arch-bows  Nos.  25  and  26.  The  two 
most  favorable  methods  for  exerting  this  force  for  the  rotation  of  front  teeth  are 
through  the  medium  of  finger-spurs  and  wire  ligatures,  both  of  which  are  fully 
described  in  detail,  with  enlarged  drawings,  in  Chapter  XIX. 

Spring  Lever  Rotators. — The  rotation  of  teeth  with  piano-wire  bars  was  first 
introduced  by  Dr.  E.  H.  Angle.  In  a  paper  presented  at  the  Illinois  State  Dental 
Society,  in  1894,  the  author  presented  the  present  modification  of  this  principle, 
which  he  is  pleased  to  say  has  rendered  this  method  of  rotating  teeth  one  of  the 
most  valuable  in  his  practice. 

For  incisor  teeth  that  are  moderately  turned,  and  for  cuspids  that  are  slightly 
turned,  the  method  is  quite  effective  if  the  principles  of  the  force  are  understood, 

339 


340 


I'MiT    VII.     UNCLASSIFIED   MALUCCLUSIO.XS 


mechanically   applied,   and   properly   controlled.      (See   "Rotating   Movements," 
Chapter   XIII.) 

Where  the  incisors  are  malturned  and  in  slight  lingual  malalignment,  resilient 
bars  or  levers  may  be  effectively  attached  in  the  manner  shown  in  Fig.  241.  But  it 
should  be  remembered  that  a  combination  of  this  character  should  never  be  placed 
upon  the  teeth  without  the  controlling  force  of  an  alignment  arch-bow.  As  ex- 
plained in  Chapter  XIII,  when  a  straight 
spring  bar  or  wire  is  firmly  attached  to  a 
tooth  and  then  bent  in  the  form  of  a  bow, 
and  the  far  end  hooked  to  an  easily  gliding 
attachment,  it  will  tend  to  rotate  the  tooth 
on  its  long  axis,  providing  the  tooth  is  pre- 
vented from  moving  laterally.  These  two 
necessary  requirements  are  obtained  with 
an  alignment  arch-bow.  It  prevents  the 
tooth  from  moving  into  labial  malalign- 
ment, and  also  serves  as  a  gliding  medium 
for  the  hook. 

The  rotating  lever  which  the  author  has 
found  most  effective  is  No.  20  or  22,  drawn 
without  annealing  from  No.  9  extra  hard  18 
per  cent  nickel-silver  wire.  This  gives  to 
the  wire  a  resiliency  nearly  equal  to  the 
piano  wire,  and  is  quite  as  effective  for  all 
practical  purposes  without  the  oxidizing 
tendency  possessed  by  steel.  Cut  the  wire 
into  13^-inch  lengths,  anneal  one  end  and 
bend  it  to  a  hook  having  the  double  curve  shown  in  the  drawing. 

The  rotating  tube  attachments — preferably  seamless — should  have  very  thin 
walls,  No.  32  or  34,  and  should  be  drawn  to  fit  the  bars  exactly,  so  as  to  hug  the 
band  and  present  no  prominent  or  irritating  edges,  and  to  take  such  position  on 
the  tooth,  when  placed,  as  will  be  most  effective  for  its  rotation.  In  placing  the 
lever,  see  that  its  length  is  such  as  to  allow  it  to  hook  to  the  arch-bow  at  an  inter- 
proximate  position  in  relation  to  the  teeth,  and  bend  the  hook  so  that  when  the 
lever  is  placed  it  will  lie  smoothly  along  the  bow.  It  will  be  noticed  that  the 
rotating  tubes  are  placed  at  the  most  favorable  position  to  obtain  the  greatest 
rotating  leverage. 

Positive  Reciprocating  Force. — For  the  rotation  of  teeth  which  are  extensively 
turned,  especially  the  cuspids,  premolars,  and  central  incisors,  the  application 
of  positive  reciprocating  force  ( a  principle  which  the  author  introduced  in  the  early 
90's)  is  certainly  the  ideal  method  for  rotating  a  tooth  upon  its  long  axis,  where 
considerable  force  and  movement  is  demanded. 


CHAPTER   XLVIII.     MALTURNED   TEETH 


341 


In  nearly  all  cases  which  require  extensive  rotation,  and  which  do  not  require 
inclination  movement,  it  will  be  found  by  a  little  study  that  reciprocating  forces 
can  in  some  form  be  applied.  A  not  uncommon  malposition  is  that  of  a  central 
incisor  turned  one-quarter  around  and  locked  in  that  position  by  adjoining  teeth, 
as  shown  in  Fig.  242.  A  No.  19  fork-end  jack,  resting  on  a  lingual  spur  hook  on  the 
malturned  incisor,  exerts  a  rotating  force,  the  reaction  of  which  being  received  upon 
the  lingual  bar  attached  to  the  right  central,  cuspid,  and  molar,  sustains  the  integ- 
rity of  the  arch,  and  exerts  a  uniform  expanding  force  to  open  the  space;  while 


Fig.  242. 


Fig.  243. 


the  ribbon  end-traction  bar,  buttoned  to  the  labial  face  of  the  malturned  incisor 
from  a  molar  anchorage,  completes  the  reciprocating  rotating  combination. 

In  the  drawing  will  be  seen  a  malturned  upper  first  premolar  which  frequently 
ofifers  great  resistance  to  rotation  on  account  of  its  bifurcated  roots.  A  simple  and 
very  effective  method  is  here  shown  for  the  application  of  the  reciprocating  forces 
of  pull  and  push  bars  connected  to  the  premolar  band  with  hinge  attachments  from 
a  molar  anchorage. 

When  one  cuspid  is  decidedly  malturned,  for  patients  older  than  twelve  or 
fourteen,  and  seems  to  offer  considerable  resistance  to  rotation,  a  very  effective 
appliance,  offering  the  application  of  direct  positive  force,  is  shown  in  Fig.  243. 
A  No.  22  (.025")  traction  arch-bow  is  cut  in  two,  giving  the  proper  length  for  each 
piece.     Short  pieces  of  No.  22-30  tubing  are  soldered  to  the  buccal  and  lingual 


342 


PART   VII.     LNCLASSIFIED  MALOCCLUSIONS 


Fig.  244. 


surfaces  of  the  cvispid  band,  and  form  the  attachments  as  in  the  former  appHance 
for  rotating  the  first  premolar.  The  cut  ends  of  the  bow  are  shghtly  annealed  to 
form  hooks  which,  when  passed  through  the  tube  attachments,  are  bent  back  on 
themselves.  The  rest  of  the  apparatus  is  plainly  shown.  The  labio-buccal  portion 
of  the  bow  may  be  employed  as  a  basis  for  correcting  malpositions  of  other  front 
teeth  the  same  as  if  it  were  a  complete  arch-bow. 

Wire  Ligatures  for  Rotating. — As  before  mentioned,  the  employment  of  wire 
ligatures  is  an  effective  method  of  rotating  and  aligning  tegth,  especially  when  there 
is  sufficient  interproximate  space  for  the  play  of  the  wire.  But  it  happens  that 
malturned  teeth  are  usually  croivded  teeth  which  are  forced  into  that  position 
because  of  the  lack  of  space.  This  means  that  their  contact  points  are  at  or  near 
the  gingival  margins.  In  order  to  pass  a  wii'e  that  is  sufficiently  large  to  exert  the 
required  force  through  this  crowded  interproximate  space  to  its  attachment  upon 
the  teeth,  its  passage  will  frequently  need  to  be  far  beneath  the  gingivae  with  pos- 
sible injury  to  the  peridental  membrane  if  allowed  to  remain  in  that  position 
long.  The  too  frequent  employment  of  these  wires  in  the  hands  of  many  who  do 
not  appreciate  this  danger,  and  especially  upon  unhanded  teeth  with  no  attachments 
to  prevent  the  wires  from  slipping  into  the  crevices,  will  doubtless  prove  in  time  the 
reaping  of  a  whirlwind  of  pyorrhea  cases,  if  no  greater  disaster  ensues.    There  are 

many  instances,  however,  where  this  method 
of  moving  teeth  is  applicable  and  effective, 
and  also  where  a  judicious  employment  of 
a  doubled  strand  of  the  smallest  size  of  the 
wires  is  a  valuable  adjunct  in  Orthodontia. 
In  the  author's  hands,  its  most  eft'ective 
application  for  the  rotation  of  teeth  is  in 
conjunction  with  a  resilient  alignment  arch- 
bow  Nos.  22  to  26,  so  that  the  elasticity 
Ui  \-n  \\-\.V^         of  the  bow  may  be  utilized  to  add  a  poten- 

tial quality  to  the  force  for  its  greater  con- 
tinued action. 

In  Fig.  244,  the  ends  of  the  wires  are 
shown  more  twisted  than  they  would  be  at 
first,  especially  upon  a  heavier  bow,  the 
purpose  being  to  show  how  they  may  be 
twisted  upon  the  lighter  spring  arch-bows 
whose  potential  resiliency  would  exert  a 
more  gradual  force  and  not  require  the  repeated  painful  renewals  of  the  liga- 
tures which  commonly  break  with  a  subsequent  twist.  The  projecting  ends  of 
the  wires  are  intended  to  be  tucked  back  out  of  irritating  prominence. 

The  most  perfect  method  of  applying  the  wire  ligatures  is  described  by  Dr. 
Angle  as  follows:   "When  applying  a  wire  ligature,  a  piece  long  enough  to  be  firmly 


CHAPTER   XLVIII.     MALTURXED   TEETH 


343 


grasped  by  both  hands  should  be  used  so  that  strong  tension  may  be  exerted  when 
making  the  twist.  This  should  never  be  more  than  three-foiirths  of  a  turn  at  first. 
The  surplus  ends  are  then  clipped  off,  leaving  projections  one-eighth  of  an  inch 
long.  These  ends  are  then  curled  under  the  arch,  thus  providing  a  smooth  surface 
to  the  lips." 

Elastic  Rings  for  Rotating. — One  of  the  most  convenient,  effective,  and  easily 
adjusted  methods  of  rotating  contruded  lower  incisors  and  other  teeth  which  are 
not  extensively  maltumed,  is  with  the  employment  of  elastic  rings.  Those  who 
have  witnessed  the  wonderful  results  accomplished  by  the  intermaxillary  elastics 
will  not  question  the  adequacy  of  the  continuous  force  when  properly  applied  for 
the  rotation  of  teeth. 

There  are  many  ways  in  which  the  elastic  rings  may  be  applied  that  will  sug- 
gest themselves  to  ingenious  minds  according  to  the  conditions  and  requirements. 

When  only  one  tooth  requires  rotating, 
a  loop  of  "Corticelli  A"  silk  ligature  may 
be  passed  over  a  lingual  pin-head  attach- 
ment, and  the  ends  carried  rmder  a  "T" 
attachment  on  the  arch-bow  and  tied  to 
an  election  ring  which  is  looped  over  the 
anchorage  attachment,  as  shown  in  Fig. 
245.  In  this  way  you  can  increase  the 
elastic  force  to  any  desired  degree  by 
doubling  the  ring  back  on  itself.  The  "T" 
attachment  is  inade  by  soldering  a  spur 
to  a  short  thin-walled  tube  of  a  size  to  exactly  fit  the  arch-bow  to  which  it  is  soft- 
soldered  at  the  required  position.  Were  it  not  for  this  attachment  on  the  bow, 
the  force  of  the  elastic  upon  the  cuspid  over  which  it  would  pass  would  contrude 
it,  unless  it  was  secured  to  the  bow  with  a  band  attachment. 


Silk  Ligatdres  for  Rotating,  Etc. 

Silk  and  linen  thread  have  been  used  for  all  time  in  the  regulation  of  teeth; 
but  the  honor  is  due  to  Dr.  W.  T.  Younger  for  first  practically  demon.strating  the 
remarkable  effectiveness  of  very  small  silk  ligatures,  and  for  special  methods  of 
securing  them  to  teeth  to  obtain  the  greatest  possible  advantage  of  their  qualities. 

For  maltumed  teeth  that  require  a  slight  rotating  force  for  their  correction, 
and  for  the  prevention  of  rotation  movement  from  the  action  or  misapplication  of 
other  forces,  "Corticelli  A"  silk  ligatures,  if  properly  applied,  will  be  found  invalu- 
able. The  retention  of  a  rotating  ligature  when  tied  to  a  tooth,  and  its  subsequent 
potential  action,  is  due  quite  as  much  to  the  elastic  resilient  quality — found  only 
in  the  smallest  of  silk  threads — as  to  the  method  of  its  application.  An  important 
advantage  of  the  smaller  sizes  is  they  are  not  so  liable  to  become  foul,  which  is  one 
of  the  unpleasant  conditions  common  with  the  larger  ligatures. 


344 


r.lKT    17/.     UNCLASSIFIED  MALOCCLUSIONS 


Fig.  24(). 


CHAPTER   XLVIII.     MALTURNED   TEETH  345 

To  tie  a  silk  ligattxre  to  a  tooth  that  will  not  slip  while  exerting  a  rotating  force, 
requires  special  methods  of  procedure.  First:  the  ligature  should  be  thoroughly 
waxed,  except  at  that  portion  of  the  middle  which  is  sufficient  to  pass  twice  around 
the  tooth  to  be  rotated.  Second:  after  passing  the  unwaxed  portion  tiuice  around 
the  tooth,  the  first  half  of  the  knot  should  be  made  by  passing  one  end  through  the 
loop  twice,  as  in  the  sailor's  tie  to  prevent  it  from  slipping  after  drawing  it  tightly 
to  place.  Third :  while  grasping  the  ends  of  the  ligature  firmly,  lift  the  tie  from  the 
tooth  with  all  the  force  which  the  ligature  will  bear  (see  "a,"  Fig.  246)  then  suddenly 
drop  the  hands  while  keeping  up  the  tension,  to  take  up  all  the  slack  ("b").  By 
repeating  this  movement  once  or  twice,  it  insures  drawing  the  double  loop  around 
the  tooth  to  its  fvillest  tension.  Fourth :  the  rest  of  the  knot  is  finished  by  passing 
the  end  through  the  loop  once,  either  way,  and  drawing  it  firmly  to  place  with  a 
slight  right  and  left  movement  ("c").  Fifth:  the  double  strand  is  grasped  and 
carried  in  the  direction  of  the  desired  force. 

The  methods  of  rotating  the  central  incisors  labio-mesially  are  shown  by  "d." 
After  tying  the  ligatures  to  both  teeth  as  described,  the  double  strands  are  again 
passed  around  the  teeth  in  the  direction  of  the  desired  force,  and  tied  with  a  sailor's 
knot  at  the  most  prominent  point  on  the  face  of  one  of  the  teeth.  The  same  move- 
ments in  tying  the  first  half  of  this  knot  should  be  made  as  in  the  first  knot,  "a" 
and  "b,"  as  much  of  the  effectiveness  of  the  method  lies  in  storing  up  all  the  poten- 
tial force  which  the  resiliency  of  the  silk  fibers  will  permit  without  breaking.  To 
prevent  the  first  half  of  this  tie  from  slipping  back  while  the  rest  of  the  knot  is  made, 
it  is  usually  necessary  for  the  assistant  to  hold  it  with  a  piece  of  orangewood. 
The  ends  are  then  cut  off  close  to  the  knot. 

"e"  shows  method  of  rotating  adjoining  incisors  that  are  malturned  in  the 
same  direction. 

"f"  shows  m.ethod  of  rotating  central  incisors  labio-distally. 

"g"  shows  method  of  rotating  a  single  incisor.  After  carrying  the  double 
strand  around  the  tooth,  it  is  separated  and  tied  to  an  adjoining  tooth  so  as  to 
produce  no  rotating  force  upon  the  latter.  Whenever  possible,  the  double  strand 
should  be  tied  to  a  double  strand  from  another  tooth  which  requires  rotating, 
though  it  may  be  quite  distantly  located.  The  potential  resiliency  of  the  ligature 
is  increased  in  proportion  to  its  length.  With  this  in  view,  the  author  frequently 
ties  the  double  strand  from  a  single  malturned  incisor  to  that  of  another  double 
strand  from  a  molar  anchorage. 

"h"  shows  method  of  rotating  a  central  and  lateral  in  the  same  direction. 

"i"  shows  method  of  rotating  the  laterals  in  opposite  directions,  or  labio- 
mesially. 

"j"  and  "k"  show  methods  of  extruding  and  intruding  a  single  incisor  with 
silk  lig-atures. 


CHAPTER   XLIX 
NARROW  AND   WIDE   ARCHES 

Laterally  Contracted  Arches  of  various  forms  and  from  various  causes  constitute 
one  of  the  common  characters  of  irregularities  of  the  teeth. 

In  the  early  history  of  the  correction  of  irregularities  by  means  of  dental  plates, 
the  lateral  expansion  of  the  arch  was  considered  the  all  important  and  necessary  pre- 
liminary step  in  nearly  all  cases  that  required  room  for  placing  the  teeth  in  alignment. 
Indeed,  so  prevalent  did  this  idea  become,  with  the  frequent  expansion  of  arches  to 
unnatural  and  disfiguring  widths  by  the  use  of  the  "Coffin"  and  other  expanding 
plates,  that  even  today  it  is  difficult  to  eradicate  that  impression  and  substitute  in  its 
place  the  far  more  important  distal  movement  of  the  premolars  and  molars  when 
demanded,  to  restore  them  to  their  inherited  positions  of  normal  occlusion,  from 
which  they  may  have  drifted  forward  through  the  premature  loss  of  deciduous  teeth, 
or  malalignments  of  the  permanent  teeth.  The  lateral  expansion  of  dental  arches, 
however,  will  always  remain  one  of  the  important  movements  in  correction. 

The  two  principal  means  employed  by  the  author  for  the  lateral  expansion  or 
contraction  of  the  dental  arch  are  those  afforded,  first,  by  the  resilient  force  of  a 
spring  arch-bow,  and  second,  by  the  positive  force  of  a  screw.  The  former  is  es- 
pecially applicable  for  expanding  or  contracting  the  buccal  area ,  particularly  in  the 
molar  region,  because  its  greatest  action  is  at  the  ends  of  the  bow  with  a  diminish- 
ing movement  as  it  approaches  the  center  of  the  bow ;  while  the  latter,  through  the 
aid  of  several  forms  of  jacks,  can  be  made  to  locate  the  force  at  any  lateral  area 
upon  either  side  of  the  arch,  or  distribute  it  evenly  to  the  two  sides  for  a  general 
expansion. 

For  extensive  expansions  of  the  arch  for  youths  and  adults,  especially  at  the 
cuspid  and  premolar  areas,  nothing  will  ever  equal  in  efficiency  the  positive  force 
of  a  screw  applied  on  the  lingual  area.  The  methods  which  are  here  presented  for 
applying  the  positive  forces  have  been  brought  to  a  high  degree  of  perfection  to- 
ward the  elimination  of  irritating  influences,  through  the  medium  of  the  "arc," 
"drop,"  and  "turn-buckle"  jacks.  Occasionally  it  is  desired  to  apply  an  independ- 
ent lingual  expanding  force  through  the  medium  of  sigmoid  shaped  wire  springs 
which  are  bent  to  conform  to  the  lingual  surfaces  of  the  gum  and  dome  of  the  arch. 
The  regular  expansion  arch-bow,  however,  which  is  placed  on  the  outside  of  the 
dental  arch,  is  far  more  frequently  demanded,  and  it  is  certainly  more  valuable 
for  the  general  expansion  of  dental  arches  in  all  directions,  because  it  enables  the 
application  of  a  variety  of  auxiliary  forces  for  the  correction  of  malalignments, 
protrusions,  and  retrusions,  and  bodily  movements  of  the  front  teeth. 

346 


CHAPTER   XLIX.     X ARROW  AXD   WIDE  ARCHES 


347 


Expansion  of  Arches  for  Children  and  Youths 

For  the  general  expansion  of  dental  arches  to  correct  crowded  malalignments 
for  children  and  youths,  extra  spring  nickel  silver  or  platinized  gold  expansion  arch- 
bows  No.  19  will  be  found  sufficiently  effective.  In  fact,  for  children  under  ten 
years  of  age,  Nos.  23,  22,  and  20,  are  commonly  employed.  These  bows  are  threaded 
at  the  ends  for  nuts  at  the  mesial  ends  of  the  molar  tubes.  The  remarkable  effective- 
ness of  the  smaller  sizes  of  spring  arch-bows  in  the  general  expansion  of  dental 
arches  is  due  to  their  resiliency  when  sprung  into  attachments  from  one  tooth  to 
the  other.  This  forces  the  malaligned  teeth,  in  their  movements  toward  correction, 
to  act  as  expanding  wedges  toward  enlarging  the  arch — an  advantage  that  is  only 
possible  with  the  smaller  bows.  This  is  the  secret  also  of  the  wonderful  effectiveness 
of  the  midget  sizes,  Nos.  24,  25,  and  26,  which  the  author  now  commonly  employs 
for  the  correction  of  malalignments  of  children's  teeth,  and  which  can  accomplish 
the  object  only  through  a  general  expansion  of  the  dental  arch. 

For  the  lateral  expansion  of  narrow  arches  for  older  patients  as  an  auxil- 
iary to  other  forces  to  correct  protrusions,  etc.,  the  larger  sizes  of  arch-bows  are 
commonly  demanded,  and  are  frequently  placed  to  act  independently  of  the 
other  correcting  forces  of  the  apparatus.  Often,  this  independent  expanding 
force  is  placed  on  the  lingual  aspect  of  the  arch,  and  composed  of  different 
forms  of  wire  springs  and  expanding  jacks. 


Bodily  Expansion 


Ftc.  247. 


When  bodily  expansion  movement  is  de- 
sired— which  is  frequently  of  the  greatest  im- 
portance on  the  upper  arch — the  expanding 
force,  whether  from  the  lingual  or  buccal 
aspect,  should  be  applied  to  the  teeth  through 
the  medium  of  root-wise  attachments,  in  order 
to  place  the  line  of  its  directed  force  nearer 
to  the  center  of  alveolar  resistance.  This  may 
be  accomplished  by  soldering  root-wise  exten- 
sions to  the  bands  of  the  teeth  which  are  chosen 
to  transmit  this  force.  See  Fig.  247;  also  see 
Anchorages,  Chapter  XV. 
In  the  employment  of  any  labio-buccal  expansion  arch-bow,  it  will  be  found 
of  great  advantage  to  have  an  open  anchorage  tube  on  one  side,  instead  of  both 
being  closed,  or  seamless.  By  placing  one  end  of  the  spring  bow  in  the  closed 
tube,  and  then  by  springing  the  other  end  into  its  seating  in  the  open-tube,  the 
full  spring  force  of  the  bow  is  obtained.  If  necessary  for  greater  security,  it  may  be 
locked  in  place.  One  of  the  greatest  advantages  is:  it  enables  an  easy  vmlocking 
of  the  arch-bow  for  renewing  its  force,  or  changing  it  in  any  way.  The  open 
mouth  of  the  tube  should  stand  slightly  inclined  toward  the  gum,  in  order  that 


348  PART    VII.     LWCLASSIFIED  MALOCCLUSIONS 

the  L'xpanding  force  of  the  how  when  sprung  into  it  wih  hrmly  retain  its  seating 
without  otherwise  locking  it.  'I'his  is  especially  important  when  plain  bows — 
without  nuts — are  employed. 

When  the  expansion  arch-bow  is  attached  to  single  molar  anchorages,  the 
molar  bands  should  always  carry  lingual  yoke  extensions,  made  of  round  or  half- 
round  wire  fitted  to  the  gingival  margins  of  the  adjoining  teeth,  to  distribute  the 
expanding  force. 

The  bodily  expanding  property  of  an  arch-bow  can  be  further  increased  by 
taking  advantage  of  torsional  force  which  may  be  imparted  to  the  bow  by  giving 
to  its  ends  a  twisted  spring  force  before  locking  them  into  their  anchorage  tubes. 
The  method  is  fully  described  in  the  chapter  on  Bodily  Movement,  and  illustrated 
in  Fig.  63,  Chapter  XIV.  It  was  presented  in  a  paper  read  before  the  American 
Society  of  Orthodontists  in  1917. 

In  a  desired  bodily  lateral  expansion  of  a  dental  arch,  if  it  were  possible,  hypo- 
thetically  speaking,  to  attach  an  elastic  buccal  pull  or  push  force  to  the  apical 
ends  of  the  roots  to  act  in  conjunction  with  a  direct  lateral  expansion  arch-bow,  it 
would  certainly  express  the  ideal  principles  of  bodily  buccal  expanding  force. 

In  the  process  of  assembling  the  torsional  bow,  the  ends  are  twisted  and  locked 
firmly  in  the  anchorage  tubes  in  such  a  manner  as  to  retain  their  potential  tor- 
sional force,  in  addition  to  the  direct  expanding  force  of  the  bow.  This  will  have  a 
great  tendency  toward  accomplishing  a  bodily  buccal  movement  of  buccal  teeth 
and  alveolar  process. 

For  all  the  ordinary  expansion  of  arches  for  children  by  this  method,  a  No.  20 
(.032  )  spring  arch-bow  is  sufficiently  heavy.  The  ends  of  the  bow  over  the  buccal 
area  are  flattened  to  a  ribbon  form  about  ^3  or  3^  the  diameter  of  the  wire,  leaving 
the  labial  portion  of  the  bow  round.  The  object  of  this  is,  first,  to  give  a  more 
resilient  spring  to  that  portion  of  the  bow  that  is  forced  into  a  twisted  state,  and 
second,  to  afford  a  means  for  holding  it  firmly  in  that  position  at  the  molar  attach- 
ments. To  fulfill  the  requirements,  the  anchorages  carry  a  flattened  seamless  tube 
on  one  side,  and  an  open  U-tube  on  the  other,  both  constructed  to  loosely  fit  the 
ribboned  ends  of  the  bow.  The  U-tube  should  be  made  of  No.  28  gauge  platinum 
gold,  or  nickel  silver,  well  reinforced  with  solder,  as  great  rigidity  is  required  to 
prevent  the  torsional  force  from  opening  the  tube.  The  U-tubes  are  soldered  to 
the  buccal  surfaces  of  the  molar  bands,  or  preferably  to  root-wise  anchorage  attach- 
ments, so  they  will  stand  slightly  inclined  toward  the  median  line.  When  one  of 
the  flattened  ends  of  the  arch-bow  is  placed  in  the  lock-tube,  as  shown  on  the  left 
of  Fig.  63,  Chapter  XIV,  the  mere  lifting  of  the  other  end  to  position  twists  the  end 
that  is  locked.  In  order  to  twist  the  other  end  of  the  bow  before  seating  it  in  the 
lock-tube,  it  must  be  firmly  grasped  with  suitable  pliers  and  forcibly  twisted  to 
its  locked  position;  this  gives  one  something  of  an  idea  of  the  force  of  reaction 
exerted  upon  the  roots  of  the  teeth.  The  bow  in  the  illustration  has  the  appearance 
of  being  flattened  only  at  one  end;  this  was  the  engraver's  error. 


CHAPTER   XUX.     NARROW  AND    WIDE  ARCHES 


349 


Fig.  24.S. 


Lingual  Spring  Expanders 

Laterally  contracted  arches  are  not  uncommon  with  no  other  irregularity 
except  that  the  front  teeth  are  forced  into  a  more  or  less  protruded  state, 
demanding  an  expansion  of  the  buccal  area  to  correct  the  front  teeth  and  the 

occlusion  of  the  back  teeth. 

If  the  teeth  do  not  require  a  bodily  ex- 
panding movement,  Fig.  248  illustrates  one 
of  the  most  simple  appliances  in  technic 
construction  and  future  management.  The 
sizes  of  the  lingual  expanding  bows  range 
from  Nos.  18  to  16  spring  nickel-silver  wire. 
The  object  of  employing  a  bow  of  a  large 
size  is  to  obtain  a  more  positive  force  to  lower 
the  range  of  its  spring  potentiality,  and  thus 
avoid  the  possibility  of  too  much  movement. 
The  bow  is  fitted  to  lie  evenly  along  the  sur- 
faces of  the  teeth  and  conform  to  the  dome 
of  the  arch.  It  is  then  sprung  outward  to  a  point  of  equilibrium  that  is  slightly 
beyond  the  desired  movement.  The  lingual  open-tubes  are  soldered  to  single  molar 
bands  in  connection  with  yoke  distributing  attachments  made  of  half-round  wire 
fitted  to  the  lingual  surfaces  of  adjoining  teeth,  by  which  means  the  expanding  force 
of  the  bow  is  communicated  to  all  the  buccal  teeth.  The  sizes  of  the  spring  ex- 
panding bows  range  from  No.  18  to  16,  determined  by  the  age  of  the  patient,  etc. 
These  molar  bands  usually  carry  buccal  tubes  for  the  regular  arch-bows.  In  assem- 
bling, one  end  is  placed  in  its  tube  attachment,  and  the  other  end  sprung  into  place. 
The  distal  nuts  shown  in  the  drawing  are  not  usually  necessary. 

There  are  other  ways  in  which  a  lingual  expanding  bow  may  be  bent  so  as  to 
conform  to  other  demands.  To  produce  a  greater  resilient  capacity,  instead  of 
crossing  the  dome  of  the  arch  immediately  t;pon  emerging  from  the  mesial  ends  of 
the  tubes,  the  bow  may  be  bent  sharply  back  to  pass  root-wise  of  the  tubes  and  then 
turned  to  cross  the  arch  further  back,  or  the  two  ends  may  be  bent  in  the  form  of 
the  letter  S. 

Instances  arise  during  or  after  considerable  lateral  expansion  of  arches,  even 
with  the  employment  of  correct  methods  for  bodily  expansion,  and  especially  when 
both  arches  have  expanded,  in  which  the  crowns  are  tipped  sufficiently  to  greatly 
disturb  their  occlusion.  When  the  broad  occlusal  surfaces  of  molar  teeth  have 
established  a  perfect  masticating  occlusion  by  use,  whether  or  not  it  be  a  normal 
interdigitation  of  the  cusps,  any  inclination  movement,  especially  in  a  buccal 
direction,  as  in  expanding  movements,  will  tilt  the  surfaces  so  that  only  the  lingual 
cusps  strike,  and  when  this  expanding  movement  has  occurred  with  the  teeth  of 
both  jaws,  it  often  leaves  a  wide  buccal  inter-occlusal  space.  If  they  are  firmly  re- 
tained in  that  position,  the  forces  of  occlusion  will  slowly  move  the  roots  bodily  to 


350 


PART   VII.     UNCLASSIFIED  MALOCCLUSIONS 


a  perfect  masticating  closure  of  the  crowns;  and  this  is  true  of  every  inclination 
of  molars,  unless  opposed  by  stronger  forces.  It  is  remarkable,  however,  how  much 
more  quickly  the  correction  can  be  effected  by  direct  intermaxillary  elastics  attach- 
ed to  hooks  on  the  gingivo-buecal  surfaces  of  the  upper  and  lower  molar  teeth.  See 
Direct  Intermaxillary  Force,  Chapter  XVI.  It  must  be  remembered,  however, 
that  the  forces  of  these  elastics  in  combination  with  the  forces  of  occlusion,  strongly 
tend  toward  a  lingual  movement  of  the  crowns  toward  their  former  malpositions, 
and  consequently,  their  expanded  positions  during  this  process  must  be  strongly 
retained  by  lingual  or  labio-buccal  arch-bows. 

Drop  Jack 

While  spring  bow  expanders  are  applicable  for  distal  areas,  the  ideal  power  for  the 
enlargement  of  dental  arches  in  every  direction  will  always  be  the  motive  force  of 
a  screw. 

Fig.  249.  Fig.  250. 


In  Figs.  249  and  250  is  shown  the  application  of  the  Drop  Jack  used  here  for  the 

ateral  expansion  of  the  arch .    The  Drop  and  Arc  Jacks  are  far  superior  to  the  straight 

jacks  for  crossing  the  vipper  arch  back  of  the  anterior  ridge,  as  they  do  not  present 

the  same  unpleasant  obstruction  to  the  action  of  the  tongue.     Patients  who  are 

greatly  annoyed  and  irritated  with  the  one,  will  wear  the  other  without  complaint. 

In  the  irregularities  shown,  the  "club-shaped"  arches  are  flattened  across 
the  front,  and  narrowed  at  the  premolar  and  first  molar  areas.    In  addition  to  the 


CHAPTER  XLIX.     NARROW  AND   WIDE  ARCHES 


351 


action  of  the  expanding  jack,  a  resilient  arch-bow  No.  20  or  22,  shaped  the  same  as 
that  shown  in  the  disassembled  appliance,  is  sprung  into  the  attachments  as  illus- 
trated. These  forces  will  tend  to  bring  the  arches  to  a  position  preparatory  to  the 
final  truing  with  the  regular  arch-bow. 

When  bodily  expansion  is  demanded,  and  it  is  desired  to  employ  the  lingual 
jack-screw  force,  root -wise  extensions  may  be  soldered  to  stationary  anchorages 


Fig.  251. 


Fig.  252. 


involving  two  or  three  teeth  on  each  side,  and  a  drop  jack,  or  even  a  .straight  jack 
may  be  made  to  rest  firmly  in  position  upon  the  lingual  bars  that  are  soldered  to 
the  root-wise  extensions.  Or  the  extensions  may  be  bent  and  fitted  before  soldering 
to  form  the  bars  upon  which  the  jack  rests. 

V-shaped  arches,  similar  to  that  shown  in  Fig.  251,  may  be  expanded,  and  the  in- 
cisors brought  to  normal  arch  alignment  with  an  expanding  jack  No.  14,  resting  upon 
an  annealed,  or  semi-hard  lingual  bow,  No.  18,  attached  as  shown  by  the  drawing. 
It  will  be  seen  that  the  lateral  expansion  of  the  bow  in  a  line  with  the  cuspids,  will 
retract  and  enlarge  its  anterior  curve,  and — if  the  anchorages  are  stationary — 
will  retrude  the  front  teeth  to  the  full  extent  of  this  movement.  If  the  contraction 
of  the  arch  is  not  symmetrical — one  side  being  contruded  slightly  more  than  the 
other — the  bow  may  be  annealed  at  the  point  of  greatest  contrusion,  and  this  will 
enable  it  to  more  readily  bend  outward  under  the  strain  of  the  jack. 


352 


PART    VII.     LWCLASSIFIKD   MALOCCLUSIONS 


If  one  side  of  the  dental  arch  is  contruded,  the  normal  side  should  be  united 

to  receive  and  distribute  the  force  of  reaction  so  as  to  permit  no  movement  of  the 

united  phalanx.    In  Fig.  252,  the  right  lingual  distributing  bow  is  extra-hard  No.  18 

wire  .screw  attached  to  the  left  central  band,  and  bent  so  as  to  rest  evenly  upon  the 

lingual  surfaces,  and  grasped  by  the  attachments  of  the  other  teeth,  as  shown.     The 

left  lingual  bow  is  semi-hard  No.  18  wire,  screw-attached  also  to  the  left  central, 

and  grasped  by  the  other  attachments,  as  shown.    The  location  of  the  jack  will  be 

governed  by  the  desired  movement,  and  its  position  changed,  as  indicated,  in  the 

progress  of  correction. 

Arc  Jacks 

The  expansion  of  the  lower  arch  is  somewhat  more  difficult  than  the  upper, 
because  of  the  required  action  of  the  tongue ,  though  patients  will  frequently  bear 
without  complaint  or  special  irritation  a  straight  jack  crossing  the  lower  arch  as 
far  back  as  the  first  premolar.  But  an  extensive  distal  location  is  now  made 
unnccessarv  bv  the  use  of  the  Arc  and  Turn-buckle  Jacks. 


Fig.  253. 


Fig.  2.54. 


Fig.  2,'5r). 


Figs.  253  and  254  show  apparatus  particularly  designed  for  expanding  the 
labial  area,  especially  of  the  lower,  to  make  room  for  the  alignment  of  incisors. 
The  lingual  bars  are  screw-attached  at  mesial  ends,  though  they  may  be  soldered 
directly  to  the  bands.  The  malposed  incisors  are  usually  brought  to  place  and 
rotated,  if  necessary,  through  the  medium  of  a  resilient  arch -bow,  with  various 
kinds  of  attachments  on  the  incisor  bands.    Fig.  255  exhibits  one  of  its  advantages 

over  the  straight  jack,  and  shows  its  relation  to  the 
dome  in  expanding  the  arch  at  the  premolar  area. 
The  action  of  this  jack  differs  from  the  drop  jack 
in  that  the  height  of  its  curve  increases,  taking 
it  farther  out  of  the  way  of  the  tongue  as  the  arch 
expands. 

The  Arc  Jack  is  one  of  the  most  important  implements  designed  for  expanding 
the  dental  arch,  and  for  other  purposes  in  orthodontia.  It  has  come  in  response  to 
the  same  need  which  created  the  Drop  and  Turn-buckle  jacks,  and  for  many 
conditions  it  is  far  superior.  It  is  made  with  different  kinds  of  attachments.  Through 


CHAPTER  XLIX.    NARROW  AND  WIDE  ARCHES 


353 


Fig.  256. 


its  end  attachments  it  can  be  placed  so  that  the  arc  is  toward  the  dome  or  toward 

the  labial  arch.    The  latter  is  especially  useful  in  expanding  the  lower  labial  arch, 

and  for  the  correction  of  many  malpositions  where  a  straight  jack  would  interfere 

with  the  tongue. 

Turn-Buckle  Jack 

The  lateral  expansion  of  the  lower  buccal 
teeth,  including  the  cuspids,  is  most  success- 
fully accomplished  with  the  Turn-buckle  Ex- 
panding Jack,  shown  in  Fig.  250.  The  distal 
ends  of  the  arms  may  be  threaded,  as  shown, 
for  hexagonal  nuts  to  be  placed  mesially  to 
the  open-tube  rests  on  the  molars. 

In  assembling  the  Tum-buckle  Expanding 
Jacks,  the  arms  should  first  be  bent  and  shaped 
to  lie  evenly  in  the  buccal  attachments,  and 
then  finally  sprung  outward  so  as  to  exert  a 
more  forcible  pressure  upon  the  posterior  teeth, 
to  act  somewhat  similar  to  the  spring  bows  at 
the  distal  areas.  The  advantage  of  the  turn- 
buckle  over  the  spring  bow  expanders  and  con- 
tractors is  that  the  screw  movement  permits 
locating  the  force  at  the  anterior  portion  of 
the  arch. 

Care  should  be  observed  in  springing  the 
arms  in  either  direction  with  the  hands,  with 
the  view  of  causing  the  appliance  to  exert  a  greater  force  at  the  distal  area,  as  it 
will  be  seen  in  such  a  movement  that  its  greatest  strain  is  brought  upon  the  points 
where  the  arms  enter  the  turn-buckle,  and  consequently  upon  the  weakest  parts 
of  the  arms,  where  they  are  deeply  threaded,  which  may  break  them,  or  bend 
them,  so  as  to  obstruct  a  free  action  of  the  screw.  Furthermore,  as  the  bends 
should  usually  be  made  at  the  angles  near  the  threaded  and  weakest 
parts,  the  heavy  wire  benders  (see  Fig.  211,  Chapter  XLII)  are 
indispensable  for  this  purpose,  unless  the  arms  are  unscrewed  and 
otherwise  grasped. 

The  "bending  pliers"  will  also  be  found  convenient  for  shaping  the 
arms  to  conform  to  the  teeth,  and  for  all  purposes  within  and  without 
the  mouth  where  heavy  bars  require  to  be  given  short  bends. 
The  cuspid  attachment  shown  in  Fig.  257,  is  usually  more  applicable  than  that 
shown  in  Fig.  256,  as  it  permits  locating  the  turn-buckle  at  a  more  distal  position. 


Fig.  257. 


CHAPTER   L 
ABNORMAL   INTERPROXIMATE   SPACES 

This  chapter  will  describe  in  detail  the  most  approved  treatment  for  closing 
all  kinds  of  abnormal  interproximate  spaces  which  have  arisen  from  natural  and 
artificial   causes. 

First  Character. — The  malposition  which  is  characterized  by  a  wide  space 
between  the  upper  central  incisors  in  the  mouths  of  children,  and  which  is  due  to  a 
low  attachment  of  the  frenum  of  the  upper  lip,  is  corrected  principally  by  a  removal 

Fig.  258. 


of  the  cause.  The  muscular  fibers  of  the  frenum  usually  extend  through  the  inter- 
proximate space  between  the  centrals  to  an  attachment  on  the  lingvial  aspect,  with 
the  result  that  every  movement  of  the  lip  causing  a  contraction  of  these  muscular 
fibers  tends  to  keep  this  space  open.  In  fact,  the  action  of  the  fibers  will  frequently 
produce  quite  a  deep  groove  in  the  interproximate  alveolar  process.  To  verify 
its  lingual  attachment,  grasp  the  frenum  between  the  thumb  and  finger  with  a 
slight  pulling  movement  which  will  cause  the  linguo-mesial  gingiva  to  turn  white, 
and  will  show  that  this  is  the  true  aponeurosis  of  the  mviscle. 

Besides  the  abnormal  appearance  which  this  malposition  produces,  it  frequently 
interferes  with  the  perfect  enunciation  of  the  linguo-dental  aspirates. 

The  Operation 

Under  the  effect  of  a  local  anesthetic,  the  frenum  is  grasped  in  locking  artery 
forceps  (see  Fig.  259),  and  its  connection  with  the  lip  is  first  completely  severed 
with  narrow  short-beak  scissors.  Then  with  a  heavy  round-end  gum  lance,  and 
while  pulling  slightly  on  the  forceps,  completely  sever  the  attachments  on  each 
side  clear  to  the  bone,  and  continue  its  extirpation  through  between  the  teeth 
including  its  lingual  attachment.  To  completely  detach  the  fibers  between  the  teeth, 
it  may  be  necessary  to  use  a  narrow  hoe  excavator  or  pointed  scaler.     All  these 

354 


CHAPTER  L.    ABNORMAL  INTERPROXIMATE  SPACES 

Fig.  259. 


355 


instruments  should  be  very  sharp  and  perfectly  sterilized.      It  is  not  sufficient 
as  a  rule  to  cut  out  a  V-shaped  piece  of  the  freniim,  because  the  deeper  located 


Fig.  2(50. 


fibers  in  the  groove  will  soon  develop  into  another  frenum,  and  thus  continue  the 
cause.  When  this  operation  is  performed  skillfully  and  thoroughly,  it  causes  the 
patient  no  pain  and  should  require  no  more  time  than  it  takes  to  describe  it. 


3.")G  rAKT    VII.     iXCLASSU<Ii:i)   MALOCCLUSIONS 

For  (iiiitc  younj^  jjatients,  the  teeth  will  usually  assume  their  normal  position 
with  little  or  no  aid  after  the  cause  is  removed.  Even  with  much  older  patients,  if 
this  is  the  sole  cavise,  and  it  has  been  thoroughly  removed,  very  simple  appliances, 
shown  under  Fig.  260,  will  readily  close  the  space;  also  retention  can  be  assured 
v.'ith  a  very  moderate  effort. 

Second  Character. — When  abnormally  wide  spaces  arise  between  the  centrals, 
and  occasionally  between  all  the  front  teeth,  for  patients  older  than  twenty-five 
or  thirty  years  of  age,  and  they  aver  that  this  condition  is  of  somewhat  recent  date, 
and  that  the  spaces  seem  to  be  gradually  increasing,  it  is  usually  due  to  the  wearing 
away  of  masticating  surfaces,  which  allows  the  jaws  to  come  closer  together  with 
a  forward  movement  of  the  entire  lower  denture,  the  latter  movement  being  due 
to  the  position  of  the  tempero-maxillary  articulation  in  relation  to  the  occlusal 

Fig.  2(il. 


plane.  See  Fig.  2(31.  If  this  occurs  with  patients  whose  lower  labial  teeth  naturally 
shear  closely  to  the  lingual  surfaces  of  the  upper,  the  lower  phalanx  will  be  driven 
with  gradually  increasing  force  between  the  lingually  inclined  planes  of  the  upper 
cuspids,  and  against  the  incisors,  with  one  of  three  results:  First,  abnormal  spaces 
will  arise  between  the  upper  front  teeth — commonly  between  the  centrals  alone ; 
second,  protrusion  of  the  upper  front  teeth;  and  third,  crowded  malalignments  of 
the  lower  incisors.  In  many  instances  the  space  between  the  upper  centrals  has 
become  so  wide  that  dentists  have  filled  it  with  an  artificial  tooth. 

While  it  is  not  difficult  to  close  the  spaces  between  the  upper  front  teeth  with 
contracting  arch-bows,  or  with  elastics  and  ligatures,  as  illustrated,  it  is  impossible 
to  permanently  retain  them  without  removing  the  cause,  except  by  a  permanent 
retainer.  In  fact,  crowded  malalignments  of  the  lower  front  teeth  are  the  most 
common  malpositions  which  arise  from  this  cause,  and  result  in  destruction  of 
interproximate  gingivae,  followed  with  pyorrhea  and  recession  of  gums  and  alveoli 
so  commonly  seen  with  patients  older  than  forty  years  of  age. 

Third  Character. — Overlapping  and  malturned  irregularity  of  the  lower  incisors 
is  one  of  the  forms  of  dental  malposition.  This  is  commonly  caused  by  a  lateral 
contraction  of  the  arch,  which  demands  the  expansion  of  both  arches.  At  times 
this  irregularity  will  occur  with  the  arches  in  normal  width,  the  upper  teeth  regular, 


CHAPTER  L.    ABNORMAL  INTERPROXIMATE  SPACES 


357 


Fig.  262. 


{\ 


and  the  buccal  teeth  in  normal  occlusion.  This  seems  to  be  due  to  the  fact  that 
the  lower  teeth  are  inharmonious  in  size  in  relation  to  the  upper.  If  it  is  due  to 
the  fact  that  the  lower  buccal  teeth  are  in  slight  mesial  malocclusion,  and  the 

patient  is  young,  and  the  occlusion  has  not 
assumed  a  fixed  position,  the  correction 
should  consist  in  retruding  the  lower  buccal 
teeth  with  the  intermaxillary  elastic  force. 
Crowded  malalignments  of  the  lower 
incisors  are  not  uncommon  with  patients 
older  than  thirty-five  years  of  age.  This 
frequently  arises  from  the  same  cause  that 
produces  the  wide  spaces  between  the  up- 
per centrals,  i.  e.,  the  wearing  down  of  the 
occlusal  surfaces  of  the  buccal  teeth.  This 
causes  the  jaws  to  come  closer  together 
and  forces  the  lower  forward  with  a  con- 
traction of  the  arch. 

As  the  incisors  are  thus  forced  into  mal- 
turned  positions,  the  gingivo-interproxi- 
mate  spaces  become  gradually  closed,  sever- 
ing the  normal  union  of  gum  tissue  between 
the  teeth,  causing  exposure  and  death  to 
the  peridental  membranes,  and  resulting  in 
absorption  and  pyorrhea,  as  shown  in  Figs.  262  and  264. 

In  these  cases  the  demand  for  the  extraction  of  a  lower  incisor  is  i)jipcratii'c\ 
and  if  this  is  followed  with  a  proper  closure  of  the  space  and  regulation,  it  will 
frequently  be  the  means  of  saving  all  of  the  lower  labial  teeth,  and  restore  the  sur- 
rounding tissue  to  a  healthy  condition;  otherwise  they  would  succumb  to  the  ab- 
normal conditions  with  ultimate  loss. 

In  closing  the  space  caused  by  the  extraction  of  an  incisor  preparatory  to 
aligning  the  teeth  in  the  correction  of  an  irregularity  where  this  operation  is 
demanded,  the  principal  object  is  to  avoid  leaving  an  inverted  V  interproxi- 
mate  space  which  will  usually  occur  with  the  ordinary  inclination  movement  of 
the  crowns. 

A  choice  of  the  particular  tooth  to  be  extracted  should  be  guided  by  the  appar- 
ent relative  distances  of  the  apical  ends  of  the  roots  from  each  other — everything 
else  being  equal — choosing  that  one  if  possible  which  is  between  adjoining  teeth 
whose  roots  are  nearest  together.  A  novice  will  commonly  choose  the  tooth  which 
is  farthest  out  of  alignment.  More  often  than  otherwise  this  is  wrong,  because  in 
the  natural  inclination  movement  of  the  crowded  crowns,  the  root  of  the  malposed 
tooth  acts  as  a  fulcrum,  and  forces  the  apical  ends  of  the  adjoining  teeth  farther 
apart;  and  as  the  difficulties  of  correction  lie  mainly  in  the  necessity  of  bodily 


358  PART   VII.     UNCLASSIFIED  MALOCCLUSIONS 

moving  the  roots  toward  each  other,  the  extent  of  the  root  movement  is  of  the  great- 
est importance. 

Tliis  is  well  shown  in  the  upper  drawings  of  Fig.  2G2.  If  the  left  lateral  which 
is  far  out  of  alignment  is  extracted,  the  movement  of  the  roots  of  adjoining  teeth 
would  need  to  be  considerable  to  properly  close  the  interproximate  space ;  whereas, 
by  the  extraction  of  the  left  central,  the  correction  might  not  require  more  than  an 
inclination  movement  of  the  crowns  alone.  Opportunities  similar  to  this  are  not 
rare.  The  usual  conditions,  however,  demand  a  more  or  less  bodily  movement  of 
the  adjoining  teeth. 

The  late  Dr.  J.  N.  Farrar,  in  his  work  entitled  "Irregularities  of  the  Teeth," 
published  in  1888,  was  the  first  to  publish  the  practical  application  of  the  prin- 

FiG,  2(>3. 


ciples  of  a  lever  of  the  third  kind  for  the  bodily  lateral  movement  of  the  lower 
incisors  to  close  wide  interproximate  spaces.  The  principles  of  his  apparatus  may 
be  briefly  explained  as  follows : 

By  attaching  a  traction  bar  at  the  gingival  margins  of  the  incisors  having 
an  open  space  between,  an  inclination  movement  will  occur  until  the  contact 
points  of  the  crowns  touch,  and  then  if  they  are  prevented  from  sliding  by,  this 
point  will  become  a  static  fulcrum,  the  teeth  becoming  levers  of  the  third  kind 
with  force  and  movement  transferred  to  the  roots.  The  mechanical  advantage 
of  this  force  will  be  increased  in  proportion  to  the  nearness  to  the  apical  ends 
of  the  roots  to  which  the  power  is  applied,  this  being  the  object  of  the  root- wise 
extensions. 

An  effective  method  for  closing  spaces  between  lower  front  teeth  after  extraction 
is  shown  in  Fig.  262.  To  wide  long-bearing  bands  fitted  to  the  desired  teeth.  No. 
18  root- wise  bars  are  soldered  and  shaped  to  conform  to  the  gum,  as  shown.  To  the 
ends  of  these  are  soldered  short  T's  for  the  attachment  of  elastics.    To  prevent 


CHAPTER  L.     ABNORMAL  INTERPROXIMATE  SPACES 


359 


Fi( 


2M. 


rotation,  which  would  naturally  occur  with  force  applied  at  so  great  a  distance  from 
the  central  axis  of  the  tooth,  the  root- wise  bars  are  attached  to  both  the  labial  and 
lingual  surfaces  of  the  bands.  This  enables  one  to  govern  the  amount  of  move- 
ment. If  irritation  to  the  tissues  is  caused  by  the  unnecessary  length  of  the  bars, 
they  are  easily  bent  in  a  distal  direction  which  is  equivalent  to  shortening  them. 
The  fork  attached  to  the  occluso-proximal  border  of  one  of  the  bands  will  pre- 
vent the  teeth  from  overlapping  when  they  come  into  contact. 

Fig.  263  shows  the  common  results' 
of  a  bodily  movement  of  the  incisors 
to  close  the  space  of  an  extracted 
tooth. 

Fig.  264,  illustrated  by  the  drawing, 
is  that  of  a  case  in  practice,  shown  in 
Fig.   265   which   was  made  from   the 
dental   casts   of   a   patient   thirty-five 
years    of    age,    whose    lower    incisors 
were  affected  with  pyorrhea  and  with 
decided  gingival  and  alveolar  absorp- 
tion,   and    resulted    in    the    necessary 
loss  of  the  two  centrals.    The  space  was  closed  with  the  apparatus,  as  shown, 
and  the  disease  was  completely  eradicated,  and  terminated  in  a  most  satisfactory 
restoration  of  the  surrounding  tissues. 


Fig.  265. 


This  case  is  a  fair  illustration  of  many  similar  cases  older  than  forty  years 
which  were  corrected  with  equal  success  in  the  author's  practice. 


Fourth  Character.    The  Closure  of  Molar  Spaces  after  Extraction 

An  interruption  in  the  development  of  the  crowns  of  the  first  permanent  molars 
during  dentition  is  not  so  very  rare.  Nor  is  it  rare  to  find  the  crowns  of  these  teeth 
at  ten,  eleven,  and  twelve  years  of  age,  so  broken  down  with  the  ravages  of  decay 
that  their  permanent  preservation  is  questionable.  When  this  occurs  in  a  dentm-e 
which  shows  by  every  indication  that  it  is  decidedly  protruded  in  its  dento-facial 
relations,  the  defective  molars,  instead  of  the  premolars,  should  be  unhesitatingly 


:?(i() 


PART    VII.     UNCLASSIFIED   MALOCCLUSIONS 


extracted,  and  appliances  placed  that  will  close  the  wide  niolar  spaces  by  a  bodily 
movement  of  the  adjoining  teeth.  See  improved  appliances  for  the  bodily  disto- 
mesial  movement  of  buccal  teeth  to  close  interi)rn\imate  spaces,  described  and 
illustrated  in  various  chapters. 

Fig.  266  was  made  from  the  casts  of  a  patient  eleven  and  twelve  years  of  age. 
The  first  four  molars  were  of  the  character  mentioned  above.  As  it  was  a  pro- 
truded upper,  the  lower  first  molars  were  temporarily  filled,  and  the  upper  were 

Fig.  2f)6. 


extracted.  The  closure  of  the  wide  spaces  by  a  bodily  distal  movement  of  the 
premolars  and  lingual  movement  of  the  front  teeth  was  accomplished  through  a 
root-wise  application  of  traction  intermaxillary  and  occipital  force.  On  the  left 
is  shown  the  beginning  facial  cast  and  dental  models  after  the  extraction  of  the 
first  upper  molars.  On  the  right  is  illustrated  the  finished  work.  It  will  be  seen 
by  the  casts  that  the  molar  spaces  are  now  completely  closed  without  the  slightest 
inclination  of  the  adjoining  teeth,  and  that  the  dento-facial  protrusion  has  been 
wholly  reduced. 


CHAPTER  L.     ABXORMAL   L\TEKPKOXIMATE   SPACES 


361 


Fig.  2G: 


Fu..  2(i.s. 


When  natvire  is  left  to  close  wide  spaces  after  the  extraction  of  first  molars,  the 
second  molars  usually  tip  forward,  destroying  perfect  occlusion,  with  the  produc- 
tion of  a  sulci  into  which  food  is  crowded  into  inverted 
\'  interproximate  spaces.  This  is  exceedingly  annoying, 
and  often  results  in  injury  to  the  teeth  and  surrounding 
membranes.  This  is  true,  moreover,  with  any  mechanical 
movement  that  is  not  especially  con- 
structed to  apply  the  proper  forces  for 
a  bodily  niovement. 

When  the  above  mentioned  broken- 
down  condition  of  the  first  molars  arises 
in  a  case  of  bimaxillary  protrusion,  they 
are  the  teeth  to  be  extracted  instead  of 
the  first  premolars,  which  otherwise  is 
the  rule.     Fig.  267  ilkistrates  a  case  of  a 
young  man  seventeen  years  of  age.    This 
case  is  fully  described  under  Bimaxillary 
Protrusions  in  Class  I,  and  illustrated  by 
Figs.  166  and  167.    Fig.  268  shows  the  buccal  appliances 
which  were  employed  in  this  case  for  bodily  closing  the 
spaces  between  the  second  molars  and  second  premolars. 
The  student  is  referred  to  the  more  modern  methods  in  root-wise  attachments 
for  the  bodily  closing  of  buccal  spaces  in  Chapter  XV  on  Stationary  Anchorages. 


CHAPTER   LI 

IA4PACTF.D   TK.F.TH   AND   TIII'JR   7'RKATMENT 

The  failure  of  certain  permanent  teeth  to  erupt  long  after  their  normal  periods 
of  dentition  has  long  been  the  cause  of  unhappy  conditions  which  demand  the 
highest  order  of  skill  to  remedy.  This  is  particularly  true  of  deep  alveolar  impactions, 
especially  before  the  days  of  modern  facilities,  when  surgeons  and  dentists  were 
groping  in  the  dark  in  search  of  a  problematical  cause  of  some  profound  condition, 
which  they  could  not  see  or  absolutely  know  existed.  And  even  when  they  were 
quite  certain  that  the  condition  was  caused  by  an  impacted  tooth,  it  was  impossible 
for  them  to  locate  its  position,  which  now  is  regarded  practically  as  an  indis- 
pensable preliminary  to  the  operation. 

Advantages  of  the  X-Ray 

Since  the  discovery  of  the  Roentgen  ray,  many  of  the  difficulties  which  formerly 
con''ronted  the  operator  have  been  removed.  The  development  and  perfection 
of  dental  radiography  makes  it  now  possible  to  determine  with  certainty  the  pres- 
ence or  absence  of  a  missing  tooth  which  is  suspected  of  being  impacted,  and  which 
gives  no  outward  indication  of  its  presence.  The  ordinaiy  radiogram  will  also  give 
a  very  fair  idea  of  the  relative  position  and  location  of  wholly  imbedded  teeth  to 
any  one  who  understands  the  peculiar  shadow  distortion  which  the  ray  is  liable  to 
throw  upon  the  plate.  This  is  a  feature  of  considerable  importance  to  one  who 
desires  to  know  the  exact  posture  and  the  location  of  an  impacted  tooth,  as  will 
be  seen  later. 

The  X-ray  will  expose  certain  causes  for  the  impaction,  that  would  otherwise 
be  unknown,  which  if  removed  will  permit  the  tootli  or  teeth  to  erupt  sufficiently 
at  least  to  allow  the  attachment  of  force  devices  for  its  final  adjustnient  in  the  arch. 
This  refers  particularly  to  supernumerary  teeth  and  odontomata,  which  are  wholly 
imbedded  in  the  process  with  the  normal  teeth,  and  in  such  a  manner  as  to  obstruct 
their  eruption,  and  which  freciuently  give  no  outward  appearance  to  the  overlying 
gum  that  would  indicate  their  presence. 

Order  of  Impactions 

In  the  author's  practice,  the  teeth  most  liable  to  be  impacted  are:  (1)  the  upper 
cuspids;  (2)  the  lower  second  premolars;  and  (3)  the  upper  central  incisors.  The 
third  lower  molars,  however,  are  perhaps  far  more  liable  to  become  impacted  than 
any  of  the  other  teeth;  and  the  third  upper  molars,  upper  second  premolars,  and 
lower  cuspids,  are  occasionally  in  this  condition.    Dr.  Cryer,  in  a  paper  published 

362 


CHAPTER  LI.     IMPACTIONS  363 

in  the  Dental  Cosmos,  January,  1904,  places  the  order  of  frequency  of  impacted 

teeth  as  follows:    (1)  the  lower  third  molars;    (2)  the  upper  cuspids;  (3)  the  upper 

third  molars;  (4)  the  upper  central  incisors;  (5)  the  lower  second  premolars;  (6) 

the  upper  second  premolars;  and  (7)  the  lower  cuspids.    His  opinion  should  receive 

respect,  based  as  it  is  largely  upon  an  examination  of  numberless  clinical  cases  and 

dried  skulls. 

Causes 

The  common  cause  of  dental  impactions  is  the  absence  of  room  in  the  arch 
for  their  free  and  normal  eruption.  The  spaces  for  the  third  molars,  which  are 
at  present  rarely  more  than  sufficient  in  Caucasian  races  for  the  normal  eruption 
and  occlusion  of  these  teeth,  seem  to  be  gradually  diminishing  through  a  foreshorten- 
ing of  the  jaws  under  the  forces  of  evolution.  These  spaces,  moreover,  which  nor- 
mally arise  for  the  third  molars  in  the  final  development  and  growth  of  the  jaw, 
are  doubtless  frequently  encroached  upon  by  slight  retruding  movements  of  the 
buccal  teeth,  through  the  forces  of  mastication  seeking  occlusal  interdigitation  of 
the  cusps.  This  may  be  one  of  the  principal  causes  for  the  retarded  eruption  and 
impaction,  especially  of  lower  third  molars,  which  are  freciuently  crowded  back 
under  the  angles  of  the  ascending  rami. 

In  Chapter  X  it  will  be  seen  that  Dr.  Cryer  has  pointed  out  the  dangers  of 
a  considerable  distal  movement  of  the  buccal  teeth  to  correct  occlusion,  which  has 
been  recently  advocated  as  an  advanced  step  in  Orthodontia,  but  one  which  could 
only  be  practiced  in  a  thoughtless  disregard  of  physiologic  demands  in  the  normal 
eruption  of  third  molars. 

A  frequent  secondary,  or  concomitant  cause  for  the  impaction  of  lower  third 
molars  and  other  teeth  is  doubtless  the  deflecting  influence  of  impinging  roots  of 
adjoining  teeth,  which  the  crowns  of  the  erupting  teeth  come  in  contact  with,  at  a 
time  when  their  roots  being  uncalcified,  the  crowns  are  easily  deflected  from  their 
true  per[Dendicular  positions  and  growth  movements.  This  turning  of  the  crown 
from  its  true  course,  which  Vv^ith  upper  cuspids  seems  to  be  caused  by  the  roots  of 
the  deciduous  cuspids,  cannot  help  but  divert  and  misdirect  the  forces  of  resorption 
which  are  necessary  for  the  growth  movement  of  the  tooth,  and  which  tends  always 
to  project  it  along  the  line  of  its  central  axis.  Moreover,  the  malposition  which 
may  commence  at  first  with  a  slight  deflection  is  probably  further  enhanced  by  the 
forces  of  eruption  and  development  of  the  root.  This  would  seem  to  be  true  in 
those  frequent  cases  of  impacted  upper  cuspids  which  lie  imbedded  nearly  or  quite 
parallel  to  the  occlusal  plane  and  with  their  crowns  just  back  of  the  incisor  roots; 
this  would  indicate  that  the  malinclination  had  principally  if  not  wholly  occurred 
before  the  roots  were  developed,  and  that  the  resorptive,  eruptive,  and  developing 
forces  had  all  tended  to  carry  the  tooth  forward  along  the  misdirected  line  of  its 
growth.    See  Fig.  269. 

In  a  very  large  proportion  of  the  impactions  of  lower  third  molars,  they  lie  in  a 
decided  mesial  inclination,  frequently  parallel  with  the  occlusal  plane,  and  with  their 


3G4 


PART    VII.     UNCLASSIFIED   MALOCCLUSIONS 


occlusal  surfaces  resting  against  the  distal  surfaces  of  the  roots  of  the  second  molars, 
and  frefiuently  with  the  points  of  the  cusps  locked  in  the  disto-cervical  depressions, 
as  shown  in  Fig.  270. 


Fig.  269. 


Fir,.  270. 

■^''m 

) 

> 

, 

■ 

m 

■^ 

Two  impacted  canine  teeth.     (To'er) 


An  impacted  second  premolar  and  a  third  molar.     (Crycr) 


In  Fig.  271  is  most  perfectly  illustrated  one  of  the  possibilities  which  may 
arise  with  impacted  third  molars. 

When  first  lower  molars  are  moved  distally  at  an  early  age,  the  crowns  of  the 
second  molars,  whose  roots  may  not  be  wholly  calcified,  are  pressed  back  with  an 


Fig.  271. 


Inverted  third  molar.     (Cryer) 


inclination  movement.  It  would  seem,  in  this  distal  movement  and  inclination  of 
the  second  molar,  that  the  overhanging  distal  surface  of  its  crown,  impinging  and 
pressing  down  upon  the  mesio-occlusal  angle  of  the  third  molar  crown,  which  at 


CHAPTER  LI.    IMPACTIONS  365 

twelve  years  of  age  usually  lies  imbedded  in  the  apical  zone  without  roots,  mesially 
inclined,  would  tend  to  hold  it  down  at  that  point,  while  the  eruptive  forces  would 
tend  to  lift  the  distal  portion  of  the  crown  and  turn  its  occlusal  surface  forward 
against  the  second  molar.  The  ultimate  calcification  of  its  roots  in  that  position 
causes  them  to  extend  back  beneath  the  angles  of  the  rami,  with  an  impaction  of 
the  tooth  which  often  demands  a  severe  surgical  operation  for  its  removal.  If  at 
eight  or  nine  years  of  age  the  first  lower  molars  are  forced  back  half  the  width  of  a 
cusp,  as  has  been  recommended  for  the  purpose  of  attaining  a  typically  normal 
occlusion,  the  unerupted  second  molars  whose  roots  at  that  age  are  uncalcified, 
are  doubtless  moved  distally  to  an  unnatural  position  in  the  jaws.  If  held  in  that 
unnaturally  retruded  position,  it  is  not  strange  that  the  mesio-occlusal  portion  of 
the  partially  developed  crown  of  the  third  molar  should  be  projected  forward  be- 
neath the  growing  roots  of  the  second  molar,  and  thus  prevented  from  following 
the  natural  course  of  its  eruption  to  an  upright  position,  with  the  production  of  an 
impaction  that  would  not  otherwise  have  occurred. 

The  late  Dr.  C.  N.  Pierce,  on  page  646,  Vol.  Ill,  American  System  of  Dentistry, 
truly  says:  "An  impacted  third  molar  at  the  base  of  the  coronoid  process  is  capable 
of  giving  as  much  excruciating  and  persistent  suffering  as  is  possible  for  htiman 
nature  to  endin-e.  Indeed,  there  is  no  abnormality  or  mission  coming  in  the  prov- 
ince of  the  oral  surgeon  which  demands  more  prompt  action,  or  for  the  time  more 
thoroughly  taxes  to  the  utmost  his  best  judgment  and  skill.  The  removal  of  the 
anterior  molar  is  often  indicated  for  the  purpose  of  giving  relief;  indeed,  when  the 
third  molar  is  imbedded  so  that  it  cannot  be  reached,  it  is  the  only  remedy."  This, 
in  the  practice  of  Orthodontia,  should  be  well  considered  before  blind  and  thought- 
less attempts  are  made  to  apply  the  intermaxillary  force  to  the  teeth  of  youths  of 
tender  ages,  in  a  frantic  endeavor  to  produce  a  typically  normal  occlusion  in  cases 
of  inherited  disto-mesial  malocclusions. 

In  a  paper  read  before  the  Chicago  Dental  Society,  January,  1905,  entitled 
"Impacted  Teeth,  Their  Liberation  and  Correction,"  the  author  exhibited  twenty- 
nine  cases  comprising  thirty-seven  impactions.  Of  these  a  few  of  the  most  interest- 
ing have  been  selected  to  illustrate  this  chapter.  Of  the  impactions,  eleven  were 
upper  cuspids;  six  were  upper  central  incisors;  ten  were  lower  second  premolars, 
and  one  was  an  tipper  second  premolar. 

Of  the  cuspids,  eight  were  accompanied,  up  to  the  date  of  presentation,  with 
the  deciduous  cuspids,  nearly  all  of  the  roots  of  which  were  not  decalcified.  It  may 
be  that  the  roots  of  deciduous  cuspids,  which  from  some  cause  the  resorptive  forces 
do  not  attack,  are  the  principal  causes  of  the  impaction  of  cuspid  teeth.  Again, 
the  deflection  of  the  crowns  may  originally  arise  from  some  other  cause  which 
enables  the  projecting  forces  of  growth  to  carry  them  so  far  to  one  side  that 
the  decalcifiation  of  the  deciduous  roots  does  not  occur.  Thus  the  deciduous 
cuspids  not  being  shed  because  of  the  unabsorbed  roots,  and  remaining  firmly 
seated  in  their  alveoli,  are  probably  allowed  to  remain  because  of  the  doubt 


30G  /MA'/'    VII.     LXCLASSJI'IED  MAIAKC Li'SIONS 

which  arises  as  to  the  presence  of  the  permanent  cuspids,  which  only  tlic  X-ray 
is  able  to  definitely  determine. 

Two  of  the  cuspid  impactions  were  caused  by  the  presence  of  supernumerary 
lateral  incisors,  and  one  by  the  premature  loss  of  the  deciduous  cuspid  which  per- 
mitted the  adjoining  teeth  to  close  the  space. 

Of  the  impacted  central  incisors,  four  were  caused  by  the  presence  of  super- 
numerary teeth,  and  two  by  odontomata. 

Of  the  impacted  second  premolars,  ten  were  caused  by  the  premature  loss  of 
the  second  deciduous  molars,  and  one  by  the  delayed  extraction  of  the  second 
deciduous  molar.  The  last  character  is  quite  commonly  observed  by  dentists. 
In  the  many  years  of  the  author's  private  and  clinical  practice,  no  less  than  fifteen 
cases  of  impacted  lower  second  premolars  from  this  cause  alone  have  presented. 
When  a  second  deciduous  molar  is  not  thrown  off  by  the  eruptive  forces  of  the 
second  premolar,  the  growth  and  crowding  nature  of  the  adjoining  buccal  teeth 
will  cause  their  crowns  to  overhang  and  entrap  it  in  their  dovetailing  inclinations 
until  it  is  forcibly  extracted.  If,  as  in  all  cases  of  this  character  which  the  author 
has  observed,  the  roots  of  the  deciduous  molars  are  completely  decalcified,  it  is  not 
difficult  to  force  the  crowns  out  through  the  buccal  or  lingual  interproximate 
spaces — the  impacted  premolars  being  found  immediately  beneath.  In  this  connec- 
tion it  is  interesting  to  note  the  difference  in  the  growth  altitudes  of  the  deciduous 
and  advanced  permanent  occlusal  planes. 

Treatment 

In  all  cases  where  the  impacted  teeth  are  necessary  for  the  perfection  and 
preservation  of  the  dental  arch,  every  means  should  be  employed  to  restore  them  to 
their  normal  positions.  The  treatment  should  consist,  first,  in  a  removal  of  the 
causes,  and  all  obstructions  to  their  free  eruption.  Where  adjoining  teeth  partially 
or  completely  close  the  space,  the  proper  appliances  .should  be  attached  for  widen- 
ing the  space  and  retaining  it  until  the  position  of  the  impacted  tooth  is  corrected. 
Deciduous,  and  supernumerary  teeth,  and  odontomata,  should  be  removed,  and 
the  overlying  gum  and  process  freely  cut  away  so  as  to  expose  at  least  the  occlusal 
portion  of  the  crown.  If  the  tooth  is  imbedded  deeply  in  the  process,  it  may  require 
several  operations  to  keep  the  wound  open.  The  inflammation  that  ensues  is 
advantageous  toward  a  stimulation  of  the  eruptive  forces,  which  having  lain  dor- 
mant for  years  are  slow  to  be  aroused  to  renewed  activities  of  tooth  growth.  During 
adolescence,  after  the  obstructions  to  the  growth  of  impacted  teeth  are  removed 
and  the  channels  of  eruption  kept  open,  without  other  aid  they  will  usually  erupt 
to  a  sufficient  degree  at  least  to  enable  the  placing  of  lightly  attached  bands  or 
caps  arranged  for  the  attachment  of  rubber  ligatures  to  co-operating  appliances. 
If  the  tooth  is  found  to  be  much  out  of  position  or  decidedly  malturned  or  inclined, 
a  more  firmly  attached  band  can  be  placed  later  to  permit  the  application  of  posi- 
tive forces. 


CIIAPTliR   LI.     IMPACriOXS 


367 


With  older  patients  it  may  be  found  impossible  to  arouse  natural  growth 
movement ;  or  the  position  and  inclination  of  the  impacted  tooth  may  be  such  that 
the  propelling  direction  of  its  growth  movement  is  of  little  use,  even  if  possible. 
In  either  event,  means  for  the  application  of  artificial  force  will  be  found  necessary; 
and  as  its  position  precludes  the  possibility  of  a  band  attachment,  a  small  pit  may 
be  bored  into  the  crown  to  attach  a  hook  for  a  rubber  ligature.  But  this  should 
never  be  attempted  until  the  crown  is  sufficiently  uncovered  to  determine  the 
relative  position  of  the  tooth  and  the  exact  anatomic  area  of  the  exposed  surface, 
in  order  that  the  hole  may  be  bored  at  some  point  on  its  lingual  surface  that  will  not 
ultimately  deface  the  tooth  when  filled,  and  particularly  to  avoid  endangering  the 
vitality  of  the  pulp. 

With  impactions  of  the  labial  teeth,  to  which  these  precautions  apply  only, 
the  position  of  the  pit  should  be  chosen  on  the  lingual  surface  of  the  crown  at 
a  point  so  that  the  drill  may  be  directed  safely  as  regards  the  pulp,  and  if 
possible,  at  right  angles  to  the  direction  of  the  recjuired  force  in  order  that  only 
a  moderate  depth  will  be  necessary  to  insure  the  stability  of  the  post  hook. 
The  choice  of  position  may  also  be  influenced  by  the  possibility  of  the  force 
prodvicing  an  unnecessary  or  necessary  rotation  of  the  tooth  in  its  movement 
to  place. 

With  teeth  that  are  so  deeply  imbedded  that  a  visual  examination  is  not 
possible,  these  requirements  often  demand  a  most  careful  and  intelligent  indirect 
digital  diagnosis,  with  an  instrument  calculated  to  sensitively  impart  the  character 
and  anatomic  conformation  of  the  freed  area. 

Fig.  272  illustrates  the  common  appliance 
employed  for  hastening  the  eruption  of  com- 
pletely imbedded  teeth.  The  adjoining  teeth 
are  banded,  and  a  bar  is  soldered  from  one  band 
to  the  other  so  as  to  take  a  position  at  the  ex- 
treme occlusal  zone.  This  acts  as  a  retainer  where 
the  space  has  been  widened  and  as  a  means  for 
attaching  elastic  bands  to  the  impacted  tooth. 
The  hole  that  is  bored  into  the  tooth  for  this 
purpose  need  not  be  deep  if  it  takes  the  proper  direction. 

The  drill  for  boring  the  hole,  and  the  wire  which  should  exactly  fit  it — with  no 
attempt  to  screw  it  in— should  be  about  No.  19  or  20.  In  placing  and  forming  the 
hook,  use  a  straight  piece  of  wire  about  five  inches  long,  well  annealed  at  the 
attachment  end.  After  cementing  in  place,  cut  the  wire  off,  leaving  sufficient 
length  to  bend  it  close  to  the  surface  of  the  gum  and  opposite  the  direction  of  force. 
This  will  cause  the  rubber  ligatures  to  hug  the  tooth  and  thus  exert  little  force 
upon  the  wire  attachment  to  dislodge  it.  When  the  impacted  tooth  has  been  forced 
out  of  its  irnbedment  sufficiently  to  enable  the  attachment  of  a  band,  it  will  com- 
monly require  another  appliance  to  place  it  in  normal  position. 


Fig.  272. 


368 


PART    III.     UNCLASSIFIED   .U  A  [.OCCLUSIONS 


A  more  furciblc  action  of  the  elastics  may  be  obtained  by  attaching  them  to 
the  teeth  of  the  opposing  jaw.  Figs.  273  and  274  illustrate  an  ingenious  and 
effective  method  which  was  proposed  by  Dr.  E.  H.  Angle  in  1891.    As  early  as  1868 


Fig.  273. 


Fig.  274. 


Ur.  Jerry  A.  Robinson  of  Jackson,  Michigan,  employed  this  same  principle,  using 
silk,  ligatures  instead  of  rubber,  by  tying  them  to  the  necks  of  the  teeth  in  a  case 
quite  similar  to  Fig.  274-,  for  a  young  man  living  in  his  family.  The  traction  liga- 
ture was  removed  at  meal  times.  The  correction  was  accomplished  in  a  short  time, 
and  retained  by  tying  the  ligatures  to  adjoining  teeth. 

Fig.  275. 


Dr.  Angle  would  probably  not  advocate  today  the  boring  of  a  hole  in  the 
face  of  a  cuspid,  as  shown  in  Fig.  273.  When  a  band  or  lightly  attached  cap  with 
a  hook  attachment  cannot  be  secured  to  a  tooth,  a  hole  can  usually  be  bored  for 

*The  author,  who  was  a  student  of  Dr.  Robinson's  during  the  time  of  the  above  operation,  was  told  that  this  was 
the  common  method  of  correcting  the  position  of  "short  teeth."  From  this  it  may  be  seen  that  direct  intermaxillary 
force  was  employed  in  dentistry  much  earlier  than  has  been  supposed. 


CHAPTER  LI.    IMPACTIONS  369 

a  pin  at  a  point  where  it  will  not  ultimately  be  a  defacement.  In  Chapter  XVIII  under 

"Construction  of  Regulating  Bands,"  is  described  the  method  of  banding  partially 

erupted  cuspids. 

The  Impaction  of  Second  Bicuspids 

Fig.  275  shows  casts  and  radiograms  of  a  boy  fourteen  years  of  age.  The  pre- 
mature loss  of  the  lower  second  deciduous  molars  had  permitted  the  adjoining 
teeth  to  completely  close  the  space  for  the  second  premolars,  as  shown  by  model 
"A."  The  accompanying  radiogram  shows  the  impacted  premolars.  The  proper 
appliances  for  opening  and  retaining  the  spaces  and  correcting  the  malocclusion 

Fig.  27(5. 


were  attached,  and  this  caused  the  impacted  teeth  to  erupt  as  seen  in  Model  "B." 
This  case  practically  illustrates  the  common  cause  and  results  of  impaction  of  this 
character. 

Impaction  of  Upper  Cuspids 

Fig.  276  is  from  casts  and  radiograms  of  a  girl  fourteen  years  of  age.  In  an 
examination  of  cast  "A"  which  represents  the  case  when  presented,  there  will  be 
found  no  abnormal  prominences  of  the  gum  surface  to  indicate  the  presence  of  the 
permanent  cuspids. 

It  is  important  to  note  in  this  and  other  cases  to  be  shown,  the  shadow  distor- 
tion of  the  position  of  the  impacted  teeth  which  the  ordinary  radiogram  is  liable 
to  produce.  Here  they  have  the  appearance  of  lying  imbedded  in  the  process  at  an 
inclination  of  45°  as  compared  to  the  normal,  and  with  the  apical  ends  of  the  roots 
quite  distally  located. 


370 


PART    Vll.     LNCLASSIFIED  MALOCCLUSIONS 


In  cast  "13,"  which  shows  the  cuspids  as  they  naturally  erupted  after  the 
removal  of  obstructions,  and  cast  "C,"  after  their  malpositions  are  corrected,  they 
are  seen  to  Ik'  in  perfect  inclination  in  relation  to  the  normal,  a  position  which  they 
could  not  have  attained  had  their  roots  been  located  as  indicated  Iw  the  radiogram. 
This  is  far  better  shown  by  the  cast  of  this  case. 

Fig.  277  is  from  casts  of  a  young  man  about  twenty-five  years  of  age.  Slight 
prominences  of  the  gum  surface  indicated  the  presence  of  the  impacted  cuspids. 


The  radiograms  also  give  to  them  the  appearance  of  quite  a  mesial  malinclination, 
which  their  erupted  positions,  shown  by  cast  "C,"  by  no  means  confirm.  It  would 
have  been  impossible  to  have  turned  these  teeth  to  the  nearly  or  quite  normal 
inclinations,  shown  by  the  cast,  had  they  been  imbedded  in  the  process  in  the  posi- 
tion which  the  shadow  distortion  of  the  X-ray  shows  them.  In  this  case,  the  pro- 
jecting force  of  eruption  has  carried  the  points  of  the  crowns  well  forward  toward 
the  lingual  aspect  of  the  central  incisors,  demanding  quite  a  decided  distal  move- 
ment in  lifting  and  forcing  them  into  alignment.  One  of  the  hooks  for  the  attach- 
ment of  the  elastic  force  is  shown  on  the  right  cuspid  of  cast  "B,"  just  as  the  tooth  is 
emerging  from  the  gum.     Cast  "C"  shows  the  cuspid  sufficiently  erupted  to  place 


CHAPTER   LI.     IMPACTIONS 


371 


bands  for  the  attachment  of  the  hngual  reciprocating  jack  for  the  final  rotation  and 
lateral  movement  of  the  crowns  into  alignment. 

Fig.  278  illustrates  the  case  of  a  girl  sixteen  years  of  age.  The  beginning  casts  "A" 
and  "B  "  show  two  fairly  well  formed  upper  laterals  on  the  right  side  and  that  no  cus- 
pid has  erupted  on  that  side.  No  prominence  of  the  gum  indicated  the  presence  of 
the  missing  cuspid.  The  supernumerary  lateral  is  plainly  located  as  the  one  next  to 
the  central,  by  its  larger  size  and  slight  difference  in  shape  as  compared  to  the  other 

Fig.  278. 


two  laterals.  Notwithstanding  the  fact  that  the  supernumerary  lateral  was  badly  dis- 
figured by  a  yellowish  channel  across  its  labial  face,  shown  by  the  preserved  tooth  and 
cast,  not  one  of  the  good  dentists  who  cared  for  her  teeth  thought  to  look  for  an  im- 
pacted cuspid  by  the  aid  of  the  X-ray  now  shown  by  the  radiogram.  As  shown  by  cast 
"  C , "  the  supernumerary  was  removed ,  the  distally  located  lateral  was  forced  forward 
to  place,  and  the  impacted  cuspid,  now  in  a  partial  state  of  eruption,  is  ready  for  the 

final  adjustment. 

Impaction  of  Upper  Central  Incisors 

Fig.  279  illustrates  the  case  of  a  girl  fourteen  years  of  age.  Cast  "A"  made  from 
an  impression  taken  at  beginning  of  operation  shows  no  prominence  of  the  gum 
surface  to  indicate  the  presence  of  the  missing  incisors.    The  radiogram  shows  the 


372 


PARl^   VII.     UNCLASSIFIED  MALOCCLUSIONS 


two  central  incisors  above  two  impacted  supernumerary  teeth,  all  imbedded  in 
the  process.  Below  these  in  the  radiogram  is  seen  the  right  lateral,  which  marks  the 
occlusal  plane.  The  radiogram  plate,  unfortunately,  was  cut  too  narrow  to  show 
the  left  lateral.  The  extracted  supernumeraries  are  seen  on  each  side  of  the  radio- 
gram. Cast  "B"  shows  left  incisor  in  partial  .state  of  natural  eruption,  and  the 
right  incisor  ready  to  burst  throvigh  the  gum. 

Fig.  280  shows  casts,  etc.,  of  a  boy  thirteen  years  of  age.    Casts  "A"  and  "B" 
represent  the  appearance  of  the  case  when  presented.    The  linguo-incisive  alveolar 


Fig.  279. 


Fic.  2S0. 


ridge  is  somewhat  prominent  but  hardly  sufficient  to  assure  the  presence  of  the 
missing  incisor,  which  is  seen  in  the  radiogram  wedged  between  two  impacted  super- 
numerary teeth.  The  latter  were  extracted  and  are  now  shown  on  each  side  of  the 
radiogram.  Cast  "C"  shows  the  incisor  in  a  partial  state  of  natural  eruption  after 
the  obstructions  were  removed.  At  this  time  band  appliances  were  attached  for 
the  regulation,  with  the  final  result  shown  by  cast  "D." 

Fig.  281  shows  casts,  etc.,  of  a  boy  of  seventeen  years.  Cast  "A"  and  radio- 
gram on  the  left  show  dental  arch  and  location  of  the  impacted  incisor.  By 
carefully  observing  the  radiogram,  the  shadow  of  a  small  dense  body  is  seen  to  lie 
at  the  incisal  edge  of  the  impacted  tooth  in  the  pathway  of  its  natural  eruption. 
This  proved  to  be  an  odontomata  about  half  the  size  of  an  incisor  crown  which  was 


CHAPTER  LI.    IMPACTIONS 


373 


loosely  imbedded  in  a  partially  absorbed  area  of  the  process.  Having  no  power 
of  its  own  to  erupt,  and  composed  of  a  structure  that  resisted  the  resorptive  elements 
it  remained  as  a  permanent  obstruction  in  the  pathway  of  the  natural  growth 
of  the  impacted  incisor.   Upon  examining  it  after  its  removal,  its  irregular  surfaces, 


Fig.  281. 


studded  here  and  there  with  enamel  prominences,  demonstrated  at  once  its  odon- 
tomatous  character.  As  the  tooth  one  year  after  this  time  presented  no  signs 
of  erupting,  the  second  radiogram  on  the  right  was  made,  which  shows  the  incisor 


Fig.  282. 


at  a  somewhat  advanced  stage,  but  evidently  retarded  in  its  growth  by  dormant 
physiologic  processes  or  obstructed  by  the  overlying  secondary  dense  tissues  which 
closed  the  original  wound.  This  was  freely  removed  as  before.  In  another  year  the 
case  again  presented  with  the  incisor  sufficiently  erupted,  as  shown  by  cast  "B,"  to 
attach  a  band  appliance  for  its  final  correction,  which  resulted  as  shown  in  cast  "C." 


374  PART    III.     UNCLASSirriil)   MAUKCIA  SIGNS 

Fig.  282  was  made  from  the  radiogram  and  casts  of  a  girl  sixteen  years  of  age 
at  presentment.  The  surface  of  the  surrounding  gum,  as  shown  by  cast  "A," 
gave  no  intHcation  of  the  impacted  incisor,  which  in  the  radiogram  is  seen  to  be 
interrupted  in  its  physiologic  eruption  by  an  odontomata  located  at  its  mesio- 
incisal  area.  This  was  removed — with  the  overlying  process — and  can  now  be 
seen  at  the  right  of  the  radiogram.  About  one  year  afterwards — during  which  time 
there  were  several  minor  operations  to  remove  obstructing  tissue — the  tooth  was 
sufificiently  erupted  for  the  attachment  of  a  l)and,  wliich  enabled  a  rapid  correction, 
as  shown  by  cast  "B." 

Let  us  hope  that  familiarity  with  the  advantages  presented  by  the  possibilities 
of  the  X-ray  will  lessen  the  number  of  cases  of  unnecessarily  lengthy  dental 
impactions  after  the  usual  ages  of  normal  eruption. 


PART  VIII 


Principles  and  Technics  of  Retention 


RETENTION  IN  DENTAL  ORTHOPEDIA 


CHAPTER   LI  I 
PRINCIPLES   OF   RETENTION 

The  art  of  moving  teeth  in  the  con-ection  of  irregularities  has  always  been 
regarded  in  the  past  as  so  nearly  the  whole  of  Orthodontia  that  the  retention 
of  corrected  teeth  has  been  largely  considered  a  matter  of  course,  and  its  impor- 
tance, difficulties,  and  uncertainty  of  permanency  have  been  lost  sight  of,  or  re- 
garded thoughtlessly  as  a  very  minor  branch  of  the  art  of  regulating.  It  is  possible 
and  even  probable  that  the  art  of  retention  will  never  approach  so  nearly  to  an 
exact  science  as  that  of  regulating,  because  of  certain  natural  influences  over  which 
one  can  have  little  or  no  control.  Yet  it  is  nevertheless  a  fact  that  the  principal 
failures  along  this  line  have  been  and  are  largely  due:  first,  to  a  lack  of  recognition 
and  appreciation  of  the  forceful  influences  of  heredity;  second,  to  a  wrong  system 
of  regulation,  which  has  led  to  placing  too  much  dependence  upon  the  normal 
locking  interdigitation  of  masticating  cusps,  after  extensive  disto-mesial  movements 
of  the  dentures  to  a  normal  occlusion;  and  third,  it  has  been  due  to  inadequate 
retaining  methods  and  appliances,  and  the  unfortunate  tendency  among  a  large 
class  of  orthodontists  to  avoid  everything  which  demands  personal  technical  skill. 

Nearly  all  writers  of  note  upon  this  subject,  from  Dr.  Norman  Kingsley  to 
the  present  time,  have  emphasized  the  importance  of  moving  the  teeth  to  positions 
of  normal  occlusion,  except  when  inadvisable  for  the  correction  of  facial  deformities, 
and  always  advising  proper  occlusal  relations  with  the  interdigitation  of  buccal 
cusps.  In  fact,  that  has  always  been  the  prime  object  of  every  one  of  even  ordinary 
ability  who  has  undertaken  the  correction  of  malposed  teeth.  It  would  seem  that 
anyone  of  ordinary  ability  must  know  that  when  teeth  are  moved  and  left  in  a 
position  where  the  masticating  forces  will  drive  them  along  the  inclined  planes  of 
opposing  cusps,  that  there  can  be  only  one  result  so  far  as  that  influence  individually 
is  concerned.  But  on  the  other  hand,  even  when  the  cusps  perfectly  interdigitate, 
and  even  though  a  state  of  normal  occlusion  is  established,  if  the  teeth  have  been 
artificially  moved  to  that  position  it  is  no  positive  evidence  that  the  occlusion 
per  se  will  retain  even  the  buccal  teeth;  nor  that  this  occlusion  and  retention  will 
insure  the  retention  of  the  regulated  front  teeth. 

Failures  of  seemingly  perfect  operations  have  so  frequently  and  persistently 
arisen  because  of  the  impermanency  of  retention,  that  it  is  not  strange  many 
dentists  have  abandoned  attempts  at  regulating  through  lack  of  confidence  in  the 

377 


378  rART    VIII.     RI:T i:\TI OX   [\    DEXTAf.   ORTI/OI'llDI A 

utility  of  an  operation  which  is  frauglit  with  so  many  difficulties  and  probabilities 
of  ultimate  failure.  Nor  is  it  strange  that  orthodontic  operations  are  so  commonly 
discredited  among  the  laity. 

In  the  earlier  years  of  his  practice,  the  author  seeing  the  failure  of  retaining  some 
of  his  most  successful  cases  and  realizing  the  inadequacy  of  the  retaining  plates  and 
devices  whicli  were  then  employed,  would  have  returned  to  the  general  practice  of 
dentistry  had  it  not  been  for  the  discovery  or  invention  of  the  present  system 
of  retention,  which  in  its  developed  stage  is  outlined  in  this  work. 

Those  who  practice  advanced  principles  of  dental  and  dento-facial  orthopedia 
and  fully  grasp  the  underlying  principles  of  retention,  and  appreciate  its  difficulties 
and  advantages,  and  who  are  aljle  and  willing  to  devote  to  it  that  high  order  of 
mechanical  skill  which  adequate  retaining  appliances  demand,  will  find  few  things 
in  dentistry  that  will  bring  quite  the  satisfaction  and  permanent  pleasure  as  the 
branch  they  have  chosen  to  practice.  And  even  these  men  must  be  prepared  to 
meet  cases  in  which  the  forces  of  heredity  will  move  the  teeth  back  toward  their 
former  malpositions  soon  after  the  artificial  restraint  is  removed,  though  perfectly 
retained  a  seemingly  sufficient  time. 

Influences  of  Heredity 

The  inheritance  of  any  family  type  of  irregularity,  from  that  of  a  single  mal- 
turned  incisor  to  extensive  protrusions  and  retrusions,  will  be  foimd  the  most 
difficult  to  correct,  especially  if  a  wrong  method  of  regulating  is  employed.  In 
cases  of  decided  disto-mesial  maloeelusal  relations  of  the  dentures — the  upper  or 
the  lower  being  protruded  or  retruded — which  are  so  frequently  due  to  heredity 
through  the  admixture  of  inharmonious  types,  one  of  the  great  principles  of  correc- 
tion with  a  view  to  permanency  of  retention  in  these  cases  is  that  fixed  inherited 
occlusions  of  the  buccal  teeth  must  not  be  changed,  except  to  slightly  adjust  them 
to  a  more  perfect  interdigitation.  In  order,  therefore,  to  correct  the  dento-facial 
outlines  and  relations  of  these  cases  in  protrusions  they  frequently  demand  the 
extraction  of  teeth,  and  in  retrusions  they  demand  opening  spaces  between  the 
premolars  for  the  insertion  of  retaining  artificial  teeth. 

The  longer  orthodontia  is  practiced,  the  more  respect  the  author  has  for  the 
general  teachings  enunciated  forty  years  ago  and  published  in  that  inestimable 
work  entitled  "Oral  Deformities,"  by  that  most  ingenious  of  all  men  of  his  day, 
Dr.  Norman  W.  Kingsley.  While  the  implements  and  appliances  used  for  retention 
in  those  days  were  very  crude  as  compared  to  those  of  the  present  time,  the  diffi- 
culties arising  in  certain  conditions  and  the  influences  of  natural  laws  remain  the 
same  and  continue  to  engage  our  most  earnest  endeavors,  often  in  futile  attempts 
to  permanence  of  retention,  even  with  the  most  perfectly  constructed  modern 
appliances.  Dr.  Kingsley  expressed  thousands  of  ideas  that  are  as  true  and  appli- 
cable today  as  when  first  written.  Indeed,  we  continually  see  in  print  these  and  many 
time-worn  important  thoughts  reclothed  and  represented  in  a  new  and  forceful 


CHAPTER   Lll.     PRiyClPLES  OF  RETENTION  379 

light,  and  too  often  introduced  and  claimed  as  discoveries  of  modern  origin.  He 
sums  up  in  the  following  words  all  that  need  be  said  relative  to  the  influences  of 
inheritance:  "In  hereditary  cases  of  extensive  character  which  have  been  delayed 
until  at  or  near  maturit}^  we  can  never  feel  certain  that  the  original  tendency  to 
malposition  so  long  unbroken  will  not  reassert  itself  at  any  time  that  we  abandon 
retaining  fixtures." 

Local  Influences 

The  physical  reacting  forces  which  tend  to  impair  or  destroy  permanency  of 
retention  of  regulated  teeth,  are  by  far  the  most  prolific. 

When  teeth  are  moved  from  a  natural  or  acquired  position,  the  strong  elastic 
and  resilient  fibers  of  the  peridental  membrane  and  surrounding  alveolar  process 
are  strained,  stretched,  and  bent,  and  unless  these  are  held  a  sufficient  time  for 
nature  to  rearrange  the  molecules  to  a  new  state  of  equilibrium,  or  supply  the 
necessary  elements  for  their  fixation,  they  are  sure  to  assert  their  power  in  forcing 
the  teeth  back  toward  the  former  malpositions. 

Occlusal  Influences 

In  regard  to  the  influences  of  occlusion  before  and  after  regulation,  the  author 
cannot  do  better  than  quote  Dr.  Kingsley  at  some  length : 

"The  occlusion  of  the  teeth  is  a  most  potent  factor  in  determining  the  stability 
in  a  new  position.  If  occlusion  of  the  teeth  will  be  such  as  to  favor  the  retention 
of  moved  teeth  in  their  new  position,  then  considerable  movement  may  be  at- 
tempted at  almost  any  age  at  which  it  might  be  desired,  and  with  an  expectation 
of  success;  but  if,  on  the  other  hand,  the  occlusion  would  be  bad,  with  a  tendency 
to  drive  them  to  their  former  malpositions,  then  all  eft'orts  at  regulating  would  be 
folly  at  any  age. 

"Teeth  could  only  be  retained  in  changed  positions  under  such  circumstances 
by  constantly  wearing  fixtures  which  would  jeopardize  their  durability  and  per- 
manence. The  wearing  of  retaining  plates  as  well  as  all  other  fixtures  upon  the 
teeth  is  tmdesirable  and  objectionable;  they  are  an  evil,  necessary  in  some  cases, 
but  to  be  avoided  as  much  as  possible.  Nevertheless,  the  fruits  of  a  skillful  and 
successful  eftort  in  regulating  teeth  must  not  be  lost  by  neglecting  to  retain  them 
in  place  until  they  not  only  become  firm,  but  the  tendency  to  return  to  their  former 
malpositions  has  been  seemingly  overcome." 

Dr.  Edward  H.  Angle  in  his  work  entitled  "Malocclusion  of  the  Teeth  and 
Fractures  of  the  Maxillae,"  has  also  expressed  many  valuable  thoughts  relative 
to  the  principles  of  retention,  which  are  worthy  of  the  careful  consideration  of  all 
who  essay  the  regulation  of  teeth.    A  small  part  of  this  teaching  is  as  follows: 

"It  should  ever  be  borne  in  mind  that  unless  the  conditions  which  have  been 
operative  in  producing  or  maintaining  malocclusion  be  removed  or  modified,  the 
establishing  of  permanent  normal  occlusion  can  rarely  be  hoped  for.  For  example, 
if  the  arches  have  been  narrowed  and  the  teeth  forced  to  take  malpositions  as  a 


380  PART   Vlll.     RETENTION  IN  DENTAL   ORTHOPEDIA 

result  of  moutli-ljreathing  due  to  pathological  conditions  of  the  nasal  passages,  it 

will  be  very  improbable  that  the  teeth  remain  in  correct  occlusion  after  the  removal 

of  the  retaining  device,  regardless  of  the  time  it  may  have  been  worn,  unless  normal 

breathing  be  established,  so  that  the  mouth  may  be  closed,  and  the  teeth  not 

deprived  of  occlusion  and  the  normal  restraint  and  support  of  the  lips  the  requisite 

amount  of  time. 

"Again,  if  irregularities  of  the  upper  teeth  have  followed  as  a  result  of  the 

diminished  size  of  the  lower  arch,  from  an  overlapped  or  irregular  condition  of  the 

lower  teeth,  it  would  be  folly  to  expect  the  teeth  of  the  upper  arch  to  be  permanently 

maintained  in  their  new  positions  unless  occlusion  be  established  by  harmonizing 

the  proportionate  sizes  of  the  arches  by  correction  of  the  positions  of  the  lower 

teeth." 

Importance  of  Interdigitation  of  Buccal  Cusps 

In  the  text  matter  of  this  work,  and  especially  throughout  specific  methods 
of  regulating,  in  Parts  VI  and  VII,  the  careful  reader  has  observed  that  one  of  the 
indispensable  principles  of  regulation  is  to  place  the  teeth  in  positions  where 
ultimate  self-fixation  will  not  be  obstructed  by  nialocclusion.  In  the  opening  para- 
graphs of  Chapter  XI,  this  feature  of  the  subject  is  particularly  dwelt  upon. 

While  a  normal  occlusion  of  the  teeth  is  eminently  to  be  desired  and  striven 
for  in  regulation,  if  for  no  other  reason  than  the  aid  it  affords  to  retention,  we 
should  not  forget  that  it  is  somewhat  rare  to  find  an  anatomically  normal  occlusion 
even  among  dentures  which  we  would  never  think  of  regulating.  But  that  which 
we  do  almost  invariably  find  in  all  cases  that  are  not  open-bite  malocclusion,  is 
that  the  masticating  forces  have  caused  the  teeth  to  adjust  themselves,  so  that  the 
cusps  of  one  set  are  fitted  into  the  depressions  and  sulci  of  the  other  with  consider- 
able accuracy,  showing  that  this  relation,  whether  or  not  in  a  normal  occlusion, 
must  be  attained,  else  nature  will  attain  it  before  she  rests;  nor  can  permanence  of 
retention  of  the  masticating  teeth  be  assured  before.  In  other  words,  a  malocclusion 
with  interdigitation  of  cusps  is  nearly,  if  not  quite,  as  capable  of  fixing  and  retaining 
the  relative  positions  of  teeth  as  a  normal  occlusion.  It  is  only  in  rare  cases  that 
we  can  hope  to  actually  improve  the  masticating  function  of  an  acquired  and  fixed 
occlusion  of  even  quite  irregular  teeth.  For  this  reason  an  acquired  or  inherited 
mesio-distal  malinterdigitation  of  buccal  cusps  with  arches  in  normal  width  should 
never  be  disturbed  except  in  those  cases  where  one  denture  is  protruded  and  the  other 
is  retruded;  and  even  then  there  are  many  exceptions  to  this  rule,  as  pointed  out  in 

Class  II  and  elsewhere. 

Importance  of  Extraction 

There  are  many  instances  of  irregularity  for  which  esthetic  relations  cannot 
be  perfectly  attained  without  extraction;  nor  can  those  cases  which  have  been 
possible  to  regulate  without  extraction  always  be  retained  with  the  same  assur- 
ance of  permanency,  because  of  the  forceful  influences  of  heredity  and  tendencies  of 
crowded  buccal  teeth  to  assume  their  former  maloositions.     The  author  refers  to 


CHAPTER   Lll.     PRINCIPLES  OF  RETENTION  381 

excessive  protrusion  of  the  upper  or  lower  teeth,  with  the  teeth  of  the  opposing 
jaw  in  normal  dento-facial  relation,  also  to  full  bimaxillary  protrusions. 

In  the  above  cases,  correction  without  extraction  would  mean  that  all  of  the 
teeth  of  the  protruded  arch  or  arches  would  require  to  be  moved  back  fully  the 
width  of  a  premolar.  While  the  author  admits  that  it  would  be  possible  to  move 
the  buccal  teeth  of  the  upper  jaw  distally  that  distance,  with  a  long  continued  and 
heroic  application  of  the  occipital  and  intermaxillary  forces  for  some  patients  not 
older  than  twelve  years,  the  same  amount  of  movement  would  not  be  possible  with 
the  lowers,  because  of  the  impossibility  of  applying  the  occipital  force;  nor  in 
bimaxillary  protrusions  would  it  be  possible  to  apply  to  the  lower  a  sufhcient  power 
from  the  combination  of  the  occipital  and  intermaxillary  forces.  And  in  any  event, 
with  molars  which  had  naturally  erupted  in  that  position — or  in  other  words, 
which  had  not  drifted  mesially  because  of  the  premature  loss  of  deciduous  teeth 
— such  an  extensive  movement  would  in  all  probability  produce  a  decided  distal 
inclination  of  the  crowns,  with  no  perfect  occlusion  thus  robbing  the  operation 
of  its  principal  if  not  the  only  element  of  retention ;  while  the  tipped  occlusal  planes 
would  constantly  tend  to  force  the  teeth  back  to  their  former  malpositions.  Moreover, 
permanence  of  retention  would  still  not  be  assured  without  the  ultimate  extraction 
of  the  third  molars.  x\nd  so  after  all,  to  satisfy  a  sentiment,  this  prolonged  and 
questionable  operation  resolves  itself  into  the  question  whether  it  is  not  better 
to  extract  a  premolar  on  each  side,  followed  by  ease  of  correction  and  assurance  of 
retention,  than  subject  the  patient  and  operator  to  far  greater  difficulties,  with 
questionable  possibilities  of  retention  and  the  final  extraction  of  the  third  molars. 

Removal  of  Causes. — Narrow  upper  arches  with  high  domes,  protruded 
V-shaped  labial  curves  with  the  buccal  cusps  occluding  in  the  sulci  of  the  lowers 
instead  of  on  the  buccal  aspect,  and  the  upper  buccal  teeth  not  lingually  inclined, 
are  not  uncommon,  and  usually  are  caused  by  a  lack  of  proper  development 
of  the  maxillary  bones  due  to  early  diseases  of  the  maxillary  and  nasal  sinuses, 
adenoid  vegetations,  degeneracy,  etc.  As  has  been  pointed  out,  correction  would 
be  futile  without  a  removal  of  the  cause.  There  is  another  equally  important 
requirement  which  pertains  directly  to  retention,  i.  e.,  the  bodily  lateral  expansion 
of  arches.     See  Chapter  XLIX. 

Importance  of  Bodily  Movement 

If  the  molar  teeth  have  been  tipped  niesially  or  distally  in  regulation,  or  if 
linguo-buccal  inclination  of  the  crowns  is  produced,  as  would  probably  occur  from 
an  expanding  jack  as  it  is  ordinarily  applied,  or  through  the  action  of  an  expansion 
arch-bow,  to  which  the  crowns  of  the  teeth  are  attached  with  wire  ligatures,  the 
occlusal  planes,  especially  of  the  molars,  will  subsequently  be  forced  back  to  a  more 
normal  occlusal  attitude.  This  has  frequently  been  the  main  cause  of  a  general 
failure  of  retention,  and  shows  the  importance  of  a  bodily  movement  of  buccal 
teeth. 


382  I'AKT    VIII.     RI-:rJ-:.\TI().\    /.V   DESIAI.   ORTIIOI'I.DI A 

T(i  this  might  also  be  added  the  teachings  of  those  eminent  writers  and  authors 

of  textbooks,   Drs.   Farrar,   Guilford,   Bogue,   (loddard,  Jackson,   and  others  on 

this  side  and  across  the  water,  to  further  show  that  all  men  of  large  experience  in 

orthodontia  recognize  and  lay  special  stress  upon  the  importance  of  the  influences 

of  inheritance  and  occlusion,  in  considering  the  permanent  retention  of  regulated 

teeth.     Beyond  this,  the  author  will  not  attempt  an  outline  of  the  various  causes 

which  operate  to  destroy  the  retention  of  moved  teeth,  nor  describe  in  detail  the 

imperfections  and  inadequacies  of  retaining  plates  and  fixtures  that  have  been  and 

are  still  being  employed. 

Summary  of  Principles 

The  most  important  underlying  principles  which  should  be  borne  in  mind  are: 

First:  Teeth  that  are  moved  by  orthodontic  processes  from  one  relative  posi- 
tion to  another  are  for  a  considerable  time — often  for  years — subjected  to  the 
physical  forces  of  surrounding  tissues  which  tend  to  move  them  back  toward  the 
irregular  positions  they  formerly  occupied. 

Second:  That  these  forces  continue  to  operate  until  the  stretched  and  bent 
fibrous  structtires  are  brought  to  equilibrium  in  their  changed  positions  by  the 
physiologic  processes  of  nature.  To  most  successfviUy  aid  nature  in  the  upbuilding 
of  sustaining  elements  and  structures,  the  moved  and  loosened  teeth  should  be 
held  relatively  still  during  the  entire  period  that  is  required  for  their  permanent 
retention. 

Third :  A  somewhat  proportionate  relation  will  be  found  to  exist  between  the 
degree  of  the  forces  required  for  movement  and  the  reactive  forces  opposed  to 
retention.  In  other  words,  if  the  movement  will  have  required  considerable  force, 
the  retaining  fixtures  will  need  to  be  of  proportionate  strength  and  stability,  unless 
the  teeth  are  brought  to  positions  of  positive  self -fixation  by  occlusion.  Again,  the 
reaction  will  always  be  along  the  lines  in  the  opposite  direction  to  that  of  the 
movements — either  rotation,  inclination,  bodily,  or  a  compound  of  these  three 
elementary  movements — consequently  the  fixture  should  be  so  constructed  and 
applied  to  completely  overcome  these  reactive  tendencies,  the  directions  of 
which  may  be  determined  by  comparing  the  beginning  and  final  casts. 

Fourth:  As  a  rule,  teeth  that  have  been  moved  slightly  are  far  more  difficult 
to  retain  than  those  of  extensive  movements,  because — as  in  ethical  relations — • 
ties  of  attachment  that  are  slightly  strained  are  far  more  liable  to  regain  their 
former  relations  than  if  completely  broken  up.  Adult  patients  frequently  apply 
for  treatment  with  no  more  than  slight  malturned  lateral  incisors,  under  the  im- 
pression that  successful  correction  can  be  easily  and  inexpensively  accomplished; 
but  these  corrections  more  often  than  otherwise  will  demand  a  permanent  fixture 
to  retain  them.  In  these  cases  the  movement  should  be  carried  considerably 
beyond  the  required  position  in  order  to  sever  as  much  as  possible  the  original 
attachments,  and  then  be  allowed  to  slowly  return  to  nearly  the  required  position 
when  the  retainer  is  attached. 


CHAPTER   LH.     PRIA'CrPLES  OF  RETENTION  383 

Fifth:  Teeth  that  have  been  moved  slowly  will  not  require  the  same  strength 
of  artificial  retention,  or  the  same  length  of  time  as  those  that  are  moved  rapidly, 
because  nature  has  had  time  to  partially  complete  the  upbuilding  elements  of 
retaining  bone  structure. 

Sixth:  While  it  is  a  fact  that  teeth  regulated  during  youth  are  more  easily 
retained  than  if  regulated  at  maturity,  or  later  in  life,  no  rule  can  be  laid  down  as 
to  the  time  retaining  appliances  should  be  worn  proportionate  to  age,  so  varied 
are  the  conditions  and  influences  that  obtain  with  different  patients.  In  nearly 
all  cases  where  the  teeth  do  not  receive  the  positive  self-retaining  support  of  oc- 
clusion, the  fixture  should  be  worn  at  least  two  years.  During  this  time  it  should 
be  removed  as  often  as  there  is  any  doubt  of  the  slightest  imperfect  ion  in  its  cement 
attachments  to  the  teeth.  At  these  times  the  teeth  shovild  be  thoroughly  cleaned, 
and  slight  malpositions,  which  the  loosened  appliance  has  permitted,  should  be 
corrected  with  silk  ligatures  before  recementing  the  appliance,  which  in  the  mean- 
time has  been  cleaned  and  properly  prepared  for  re-attaching.  Though  a  retainer 
may  at  times  be  worn  from  one  to  two  years  without  removal  and  without  injury 
to  the  teeth,  six  months  should  be  the  limit,  though  seemingly  perfect  in  its  cement 

attachments. 

Imperative  Demands  in  Retaining  Fixtures 

To  render  the  most  aid  in  the  upbuilding  of  tissues  for  the  permanent  retention 
of  regulated  teeth,  the  retaining  fixture  should  be  one  that  so  firmly  grasps  the 
teeth  that  the  several  opposing  forces  are  completely  held  at  bay,  except  for  the 
slight  normal  movements  occasioned  by  mastication,  etc. 

Anything  in  the  form  of  a  retaining  plate  which  recjuires  fi-ecjuent  removals 
for  cleansing  is  objectionable  and  far  inferior  to  a  cement-attached  appliance  for 
holding  the  teeth  firmly  in  the  desired  positions. 

The  fixture  should  be  as  perfectly  fitted  and  cemented  to  the  teeth  as  a  bridge 
denture,  and  so  constructed  that  the  teeth  and  gums  can  be  kept  in  a  healthy 
condition  while  it  is  worn,  with  the  same  comfort  and  unconsciousness  that  a 
filling  or  artificial  crown  produces. 

To  fulfill  these  demands,  its  appearance  in  the  mouth  is  of  the  utmost  importance. 
Patients  will  svibmit  to  long,  tedious,  and  painful  operations,  often  with  cumbersome 
and  unsightly  apparatus,  stimulated  by  the  hope  of  ultimate  success,  but  when  the 
teeth  are  finally  brought  to  a  satisfactory  position,  they  naturally  object  to  a  long 
and  continued  use  of  any  form  of  appliance  objectionably  conspicuous  or  annoying. 

One  of  the  greatest  objections  to  an  attached  fixture  is  the  danger  from  decaying 
detritus  lodged  in  the  pockets  of  imperfectly  cemented  bands  and  unccmented 
extensions,  which  if  allowed  to  remain  will  wreck  the  underlying  enamel.  To  avoid 
this,  the  best  of  retaining  appliances  should  be  carefully  examined  every  two  or  three 
months,  and  patients  also  should  be  warned  in  regard  to  the  danger  of  leaving  the 
appliance  upon  the  teeth  after  they  discover  that  any  one  of  the  bands  has  become 
loosened  and  is  in  any  way  pocketing  decaying  foods  or  unhealtliful  secretions. 


CHAPTER   LIII 
LABIAL   RETAINING   FIXTURES 

It  will  be  observed  in  the  following  description  of  retaining  appliances  for  front 
teeth,  that  the  author  avoids  as  far  as  possible  the  employment  of  uncemented 
extensions  or  bars  lying  upon  imbanded  teeth.  Though  they  may  at  times  be  used 
with  safety,  he  prefers  that  retaining  fixtures  shall  be  composed  of  united  bands, 
which  are  perfectly  fitted  and  cemented  at  all  parts  in  contact  with  enamel.  Another 
important  object  in  firmly  cemented  bands  is  to  secure  relative  immovability 
against  the  strong  tendencies  of  the  forces  of  reaction,  thus  preventing  anything 
more  than  the  slight  normal  movements  of  mastication.  Moreover,  it  is  a  some- 
what rare  occurrence  even  with  minor  irregularities,  that  all  of  the  front  teeth  are 
not  moved  more  or  less,  and  therefore  demand  a  proportionate  retaining  fixture. 

As  a  rule,  all  fixtures — even  those  for  the  retention  of  a  single  tooth — demand 
at  least  two  carefully  fitted  and  cemented  bands.  When  more  than  two  teeth 
are  involved  in  a  labial  fixture,  the  pier  bands  are  the  only  ones  which  need 
to  completely  encircle  the  teeth ;  and  these  may  be  quite  narrow  in  front  to  be  less 
conspicuous.  The  bands  for  the  intervening  teeth  are  cut  away  in  front,  leaving 
only  a  small  portion  to  lap  on  either  side,  and  joined  with  a  solid  clip  to  insure  a 
stable  grasp,  as  will  be  described. 

Quality  and  Thickness  of  Bands 

The  pier  bands  of  the  appliance  are  narrowed  in  front  and  usually  cut  to  con- 
form to  the  gingival  border.  These  are  now  made  of  platinum-gold.  The  cuspid 
bands  in  a  six-band  appliance,  as  in  Fig.  290,  are  .0045"  in  thickness.  In  a  four- 
band  appliance  attached  to  the  incisors  alone,  the  pier  bands  are  .004".  For  inter- 
vening bands,  the  fronts  of  which  are  nearly  cut  away,  nickel-silver  is  preferable, 
because  of  its  greater  strength  and  sufiiciently  high  fusibility.  These  bands  rarely 
need  to  be  thicker  than  .003". 

Bands  for  retainers  should  always  be  as  thin  as  the  required  strength  will 
permit  in  order  to  leave  the  smallest  possible  spaces  at  contact  points  while  the 
appliance  is  in  position.  Also  all  portions  of  the  fronts  that  are  not  absolutely 
required  for  stability  of  retention  should  be  narrowed  or  cut  completely  away. 

All  exposed  surfaces  of  the  intervening  nickel-silver  bands  should  be  com- 
pletely covered  with  platinum-gold  in  the  reinforcing  and  soldering  process.  In  an 
appliance  involving  four  or  more  teeth,  a  clasp-metal  plate,  No.  28  gauge,  is  swaged 
and  soldered  to  the  lingual  surfaces  of  the  bands,  as  will  be  described,  to  reinforce 

the  stability  of  the  fixture. 

384 


CHAPTER  LIII.    LABIAL  RETAINING  FIXTURES  385 

Technics  of  Construction 

To  illustrate  the  principles  which  have  been  outlined,  we  will  first  consider  a 
simple  irregularity.     See  Fig.  283. 

Fig.  284  is  a  common  but  very  questionable  retaining  fixture  which  consists 
of  a  bar  passed  through  a  rotating  tube  attachment,  or  soldered  directly  to  the  band. 
This  fixture  can  be  made  less  irritating  to  the  lips  and  more  inconspicuous  and  per- 
manent by  bending  a  D  clasp-metal  wire  to  conform  to  the  labial  surfaces  and 


Fig.  283. 


Fig.  284. 


Fig.  285. 


Fig.  286. 


soldering  it  to  a  perfectly  fitted  platinum-gold  band.  The  labial  borders  of  the 
bands  are  then  trimmed  nearly  to  the  wire,  and  the  whole  perfectly  finished  and 
gold-plated.  See  Fig.  285.  The  uncemented  extensions,  which  lie  upon  the  adjoining 
teeth,  should  be  slightly  convex  on  the  under  surface  and  perfectly  finished,  and  the 
patient  required  to  frequently  clean  them  with  floss  silk. 

As  uncemented  extensions  are  at  best  often  dangerous  to  the  enamel  upon  which 
they  rest,  for  young  and  somewhat  careless  patients  the  author  prefers  the  appliance 
shown  in  Fig.  286.  The  outer  pier  bands  of  all  retainers  are  platinum-gold,  with 
joints  on  the  lingual  aspect,  and  the  intervening  bands  are  nickel-silver  with  joints 
on  the  labial.    The  joints  of  all  retaining  bands  are  soldered  with  22k  gold  solder. 


Fig.  287. 


Four-Band  Retainer 

Fig.  288. 


Fig.  289. 


^:::X=^ 


In  Fig.  287,  both  laterals  are  malturned. 

Fig.  288  shows  an  improvement  over  the  bar  attachment  that  is  commonly 
recommended.     In  construction  it  is  similar  to  Fig.  285. 


386 


PART    VIII.     RI-:TI-:\I11)\    I\    DF.X/A/.    OKIIIOI'I-.DIA 


Fig.  290. 


Fig.  2(S9  shows  the  :ii)])li;i,nce  whicli  is  far  ])n'fc'rablc.  Its  tcchnic  construction 
is  similar  to  the  "six-hand  retainer."  It  vviH  he  found  efiually  applicable  where  all 
of  the  incisors  are  malturned  but  in  alignment  with  cusjnds  that  are  properly  posed. 

Six-Band  Labial  Retainer 

In  a  large  proportion  of  irregularities,  all  of  the  labial  teetli  are  more  or  less 
malposed,  or  require  to  be  moved  to  bring  about  a  proper  arch  alignment  and 

occlusal  relation;  therefore,  the  most  common  retaining 
appliance  is  that  which  includes  the  six  front  teeth. 
See  Fig.  290.  This  was  fir.st  published  in  the  Ohio  Dental 
Journal,  January,  1898,  and  represents  the  standard  re- 
taining appliance  which  the  author  has  successfully  em- 
ployed in  his  practice  during  the  last  twenty-five  years. 

It  has  been  found  that  by  holding  the  labial  teeth 
hrmly  in  their  relations  to  each  other,  they  rarely  move 
in   plialanx,  even  after  the  correction  of  qviite  decided 
protrusions  or  retrusions.     Again,  after  the  correc- 
tion of  narrow  V-shaped  arches,  by  preventing  the 
labial  teeth  from  reacting,  the  premolars  and  even 
the    molars    rarely    move,    though    not    otherwise 
sustained.      In   cases   of  decided  protrusions   and 
retrusions,    however,    and    particularly    when    the 
incisors  have  been  moved  bodily  in  phalanx,  pro- 
vision is  always  made  for  lingual  bars  to  the  molars  to  overcome  the  tendency 
toward  reaction.    Supplementary  attachments  to  the  labial  retainers  will  be  found 
fully  described  in  Chapter  LIV. 

Unless  the  labial  retainer  can  be  constructed  with  the  same  skill  reciuired 
for  crown  or  bridge  dentures,  it  had  better  not  be  attempted,  because  it  will  fall 
short  of  its  desired  object,  and  may  easily  result  in  a  thing  which  cannot  even  be 
placed  on  the  teeth,  or  one  which  if  attached  will  not  hold  the  teeth  firmly,  or  will 
in  itself  force  them  to  irregular  positions. 

Long  experience  in  its  use  has  taught  the  importance  of  certain  exact  require- 
ments in  its  construction  which,  if  followed,  will  result  in  an  appliance  that  will  fulfill 
every  demand,  and  one,  moreover,  which  the  most  fastidious  patient  will  not 
object  to  wearing  the  required  time. 


Details  of  Constructing  the  Six-Band  Labial  Retainer 

When  the  teeth  are  regulated  or  moved  slightly  beyond  their  correct  positions, 
no  force  should  be  exerted  through  the  medium  of  the  regulating  apparatus  for  a 
week  or  two,  except  that  which  may  be  accomplished  with  light  silk  ligatures  to 
hold  the  teeth  or  true  them  up.  As  it  is  always  desirable  to  place  the  retainer  the 
same  day  that  the  apparatus  is  removed,  an  early  appointment  is  made  in  order 


CHAPTER   LIII.     LABIAL   RhlTAIMXG  FIXTURES 


3S7 


«/,M 

Fig.  291 

^  , 

N 

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■ 

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s 

K 



,/^J 

'<%^ 

/- 

X  ^- 

/ 

\ 

to  have  plenty  of  time ;  though  in  an  expert  handling  of  the  work,  two  and  sometimes 
three  of  these  appliances  can  be  made  and  placed  in  one  day. 

When  the  regulating  apparatus  is  removed,  the  teeth  are  cleaned  preparatory 
to  taking  the  measurements  and  fitting  the  bands,  as  described.  At  this  time  it 
will  frequently  be  found  that  the  teeth  are  not  quite  in  the  exact  positions  they 
appeared  before  the  apparatus  was  removed,  or  they  may  have  sprung  slightly 
out  of  place  after  its  removal.  This  is  especially  true  of  malturned  teeth  which 
have  not  been  carried  beyond  their  normal  positions — as  they  should  be.  In  this 
event  a  skillful  tying  and  management  of  "Corticelli  A"  silk  ligatures  will  usu- 
ally correct  the  positions  during  the  time  the  bands  for  the  retainer  are  being 
soldered  preparatory  to  fitting.  Occasionally,  they  will  require  a  second  tying, 
and  at  times  it  will  be  well  to  postpone  fitting  the  bands  until  the  next  day  to 
obtain  the  required  positions. 

In  order  that  cuspid  bands — which  are  the  only  ones  in  the 
six-band  retainer  which  encircle  the  teeth  when  finished — be  as 
inconspicuous  as  possible,  they  are  cut  after  a  pattern  (Fig.  291), 
which  provides  for  a  wide  lingual  portion  with  joint,  and  a 
narrow  labial  portion,  which  conforms  to  the  gingival  line. 
When  properly  soldered,  fitted,  and  contoured,  this  pattern 
will  be  found  to  fit  perfectly  every  cuspid. 

In  preparing  to  construct  the  cuspid  pier  bands,  a  piece  of 
platinum-gold,  .0045"  in  thickness  and  liV  wide,  is  annealed 
and  marked  as  shown  by  the  straight  lines  in  Fig.  291.  A  little 
practice  will  enable  one  with  a  delicate  pair  of  curved 
manicure  scissors  to  cut  the  band  according  to  the 
pattern  shown  below.  The  thickness  of  this  band  with 
that  of  the  adjoining  one  will  produce  abovit  as  much 
space  between  the  cuspid  and  lateral  as  would  be 
caused  l)y  two  layers  of  common  writing  paper;  and 
this  can  be  reduced  at  the  contact  point,  if  desired, 
with  a  paper  disk.  See  Fig.  292. 
The  incisor  bands  should  never  be  thicker  than  .003",  preferably  of  nickel 
silver.  Alternate  bands — as  for  instance  the  right  lateral  and  left  central — may 
be  sufficiently  wide  to  extend  beneath  the  interproximate  gingivae.  The  extra 
width  insures  the  interproximate  portions  of  alternate  bands  to  serve  as  entering 
wedges  in  the  first  placing  of  the  appliance  after  it  is  soldered.  This  will  be  more 
fully  appreciated  in  the  later  description,  and  especially  in  practice. 

Preparatory  to  fitting  the  bands  on  the  teeth,  the  labio-gingival  borders  of  the 
incisor  bands  may  be  trimmed,  as  shown  in  Fig.  293,  though  this  is  not  important. 
The  occlusal  borders  should  be  trimmed  free  from  the  incisal  edges,  being  sure  that 
the  contact  points  of  the  teeth  are  well  covered.  It  is  next  to  impossible  to  fit  a  thin 
wide  band  that  requires  forcing  on  and  oft'  the  teeth  several  times  without  proper 


Fig.  292. 


38S 


PART   VIII.    RETENTION  IN  DENTAL  ORTHOPEDIA 


tools,     'ilic  hardwood  plugger  and  band-removing  plicr  will   be  found   invaluable 
in  this  operation. 

The  bands  are  perfectly  fitted  and  i)urnished  to  the  ine(|ualities  of  the  lingual 
surfaces  of  the  teeth,  and  a  partial  impression  is  taken  in  investing  plaster,  using 
only  sufficient  material  to  submerge  the  bands.  The  bands  are  then  carefully 
removed  from  the  teeth  with  the  removing-plier,  and  accurately  placed  in  their 
respective  positions  in  the  impression,  Fig.  294,  and  the  approximating  surfaces 
arc  filled  with  Taggart's  wax,  using  the  point  of  a  hot  spatula  to  drive  it  between 


Fig.  29.3. 


Fig.  294. 


Fig.  295. 


Fig.  296. 


the  bands.  Any  slight  portion  of  the  wax  which  runs  into  the  1-^ands  must  be  com- 
pletely removed,  and  the  surface  scraped.  A  thin  solution  of  plumbago  is  used  for 
separation.  This  should  thoroughly  cover  the  plaster  surfaces  and  the  insides 
of  the  bauds.  If  it  were  not  for  the  wax  between  the  bands,  the  plumbago  would 
flow  between  their  interproximate  surfaces  and  prevent  the  flow  and  perfect  union 
with  the  gold  solder.  Again,  if  wax  is  allowed  to  remain  on  the  inner  surfaces  of 
the  bands,  it  will  cause  the  solder  to  flow  there.  The  object  in  painting  the  surfaces 
with  plumbago  is  to  prevent  the  slightest  portion  of  solder  from  reaching  and  ad- 
hering to  these  surfaces,  as  this  might  easily  prevent  the  entire  appliance  from  going 

to  place. 

The  impression  is  now  filled  with  investing  plaster, 
and  the  model  with  the  bands  in  place  is  trimmed  to  a 
minimum  size  of  stability  for  soldering.  In  separating, 
the  lingual  portion  of  the  impression  is  saved,  as  shown  in 
Fig.  295,  from  which  is  obtained  the  die  for  swaging  the 
lingual  reinforcement-plate,  which  is  made  of  No.  28 
gauge  clasp-metal.  This  is  well  shown  in  Figs.  296  and 
297,  swaged,  trimmed,  and  placed  in  position  to  solder. 
It  should  be  cut  a  little  narrower  than  the  bands  to  facili- 
tate placing  and  drawing  the  gold  solder  beneath,  which 
should  finally  be  fiowed  over  its  entire  surface.  It  is  of 
the  utmost  importance  to  stift'en  in  this  way  the  six-band 
labial  retainer  to  prevent  the  reacting  forces  from  changing  the  corrected  curve  of 
the  arch,  especially  in  all  cases  where  the  arch  has  been  laterally  expanded. 


Fig.  297 


CHAPTER  LIII.    LABIAL  RETAINING  FIXTURES 


389 


Fig.  298. 


dr^ 


m 


ID 


I 


a. 


o 


^<^-':r^^ 


To  avoid  an  excess  of  solder  with  its  contracting  pos- 
sibilities, an  important  device  is  now  employed  for  filling 
and  finishing  the  labial  portion  of  the  interproximate  ex- 
tensions which  lap  on  to  the  labio-proximate  angles  of 
the  incisors — the  intervening  portions  of  the  bands  being 
cut  away.  This  consists  in  striking  up  small  gold  clips 
which  exactly  fit  the  sulci  and  leave  slightly  convex  labial 
surfaces  for  artistic  finish. 

The  dies  for  this  device  are  easily  made  as  follows: 
From  a  /^-inch  square  steel  rod  (or  any  scrap  piece  of  steel) 
cut  two  pieces,  "a"  and  "b,"  Fig.  298.  Across  the  center 
of  "a,"  cut  a  groove  with  a  sharp-edged  file  in  the  form  of 
the  labial  interproximate  sulci.  The  other  piece  is  for 
the  plunger  die  "b."  First  fit  one  end  perfectly  to  the 
groove,  and  then  cut  out  a  place  with  a  rotmd  file  and 
slightly  concave  it  with  a  round  corundum  stone  to  form 
the  space  in  which  to  strike  the  clip. 

The  clips  are  made  of  scrap  clasp-metal  pieces  weigh- 
ing about  two  grains,  and  are  fused  on  the  solder-block 
which  being  placed  at  the  center  of  the  groove  "a"  with  the 

Two  views  of  the 
and  "e."    A  con- 


to  form  tiny  balls,  "c 

die  evenly  in  position  are  quickly  struck  to  the  desired  forms. 

clips  and  the  original  ball  of  metal  are  shown  enlarged  at  "c' 

venient  guide  "d"  to  the  plunger  is  easily  made  of  28-gauge  plate.      A  square  is 

made  and  fitted  to  the  counter-piece,  with  an  opening  cut  for  the  groove.    To  this 

is  soldered  a  box  which  fits  and  guides  the  plunger  die  directly  into  the  groove. 

The  investment  containing  the  bands  should  be  trimmed  to  stand  on  a  firm 
base  with  the  labial  surfaces  uppermost.  When  it  is  thoroughly  dried  with  a  blow- 
pipe, and  the  interproximate  spaces  luted  with  fused  borax,  place  on  edge  in  each  one 
of  the  sulci  a  small  piece  of  No.  18k  gold  solder  and  flare  the  soft  blaze  back  and  forth 
over  the  entire  piece  from  a  direction  that  will  cause  a  part  of  the  heat  to  reach  the 
lingual  surfaces.  With  this  movement,  the  solder  when  fused  will  be  drawn  through 
between  the  teeth  and  will  thoroughly  penetrate  and  fill  the  entire  interproximate 
spaces.  The  three  central  clips  can  now  be  placed,  being  careful  to  place  them  exactly 
over  the  contact  points  of  the  teeth,  and  with  the  same  character  of  blaze  draw  them 
to  position  using  a  steel-pointed  instrument  dipped  in  plumbago  for  a  teaser.  It  is 
usually  necessary  to  add  small  pieces  of  solder  to  their  edges  to  complete  the  work. 

The  investment  piece  is  then  partly  tilted  upon  its  ends  to  facilitate  placing 
and  soldering  the  other  two  clips.  Now  turn  the  investment  over,  resting  it  firmly 
in  a  concaved  block.  The  entire  lingual  surfaces  of  the  bands  being  luted  with 
fused  borax,  adjust  and  fit  the  clasp-metal  reinforcement  piece,  and  hold  it  firmly 
in  place  at  the  center  with  a  teaser,  while  tacking  it  at  this  point,  and  then  at  the 
ends.    Place  fairly  large  pieces  of  solder  at  one  edge  of  the  reinforcement,  and  draw 


390  I'ART    VIII.     Rl:'r l:\riON   IN   DENTAL   OKTIUil'IJ)! A 

tlu'ni  first  beneath  it  1)\-  iliivetiii<^^  the  lieat  mostly  at  tlic  other  edye.  Finally, 
smootli  and  linish  with  a  minimtmi  amount  of  solder. 

After  the  borax  is  removed  in  the  sulphuric  acid  Ijatli,  the  lingual  surface  is  first 
finished  at  the  lathe.  In  finishing  the  front,  use  a  thin-edged  stone  with  the  dental 
engine,  and  grind  around  the  cHps  until  the  inter-portions  of  the  bands  to  be  cut 
away  are  nearly  or  quite  severed.    Finally,  finish  with  sandpaper  disks,  and  polish. 

In  the  entire  process  of  finishing,  the  piece  should  be  handled  with  delicacy 
and  with  special  care  to  avoid  bending  the  frail  interproximate  extensions  to  one 
side  or  the  other,  as  this  will  tend  to  fracture  or  weaken  them.  To  prevent  the 
solder  from  producing  thickened  portions  in  the  interproximal  spaces  above  the 
contact  point,  the  bands  should  Ijc  pressed  closely  together  at  the  stage  shown  in 
Fig.  294,  before  filling  the  impression.  Another  important  move  at  this  time 
is  to  burnish  the  gingivo-lingual  edge  of  the  band  firmly  against  and  slightly  into 
the  plaster  impression,  as  it  is  liable  to  contract  in  the  soldering  and  thus  prevent 
the  appliance  from  going  fully  to  place  over  the  linguo-gingival  ridges. 

Placing  the  Appliance 

The  general  flare  of  the  labial  teeth  often  occasions  considerable  difficulty 
and  pain  in  placing  the  appliance  when  finished.  This  has  been  one  of  the  greatest 
drawbacks  to  its  general  adoption,  though  much  has  been  due  to  the  lack  of  perfect 
accuracy  and  care  in  its  construction,  and  partly  due  to  the  natural  contraction  of 
the  solder.  Therefore,  the  smallest  amount  of  solder  permissible  in  obtaining  a 
smooth  finish  should  be  used. 

As  an  extra  precaution  toward  aiding  in  the  easy  placing  of  the  appliance, 
narrow  thin  separating  tape  is  placed  between  the  banded  teeth  (Fig.  293)  and 
cut  oft'  close  just  before  taking  the  impression.  At  this  time  also,  light  adjustment 
ligatures  for  the  final  truing  up  of  the  teeth  may  be  placed  if  required. 

The  difficulty  in  forcing  a  six-band  appliance  to  place  for  the  first  time  makes 
it  usually  necessary  to  place  it  temporarily,  to  remain  about  a  week  to  allow  the 
teeth  to  become  adjusted  to  it,  so  that  the  final  placing  can  be  made  with  the 
rapidity  required  by  the  setting  cement. 

Moreover,  this  first  placing  of  the  appliance  will  rarely  be  possible  if  started  at 
the  cuspids.  It  should  be  started  between  the  centrals,  then  the  laterals,  and  finally 
the  cuspids.  When  it  is  forced  to  a  starting  position  upon  all  of  the  teeth,  it  can  then 
be  easily  malleted  to  place  with  a  wood-plugger,  and  finally  with  a  thin  imserrated 
foot  plugger,  to  drive  home  the  interproximate  portions.  The  interproximo-gin- 
gival  extensions  of  alternate  bands,  previously  mentioned,  will  act  as  entering 
wedges,  and  often  facilitate  the  first  placing,  especially  with  beginners.  In  the 
author's  practice,  however,  where  two  of  these  appliances  are  n:iade  and  placed 
in  one  day,  this  feature  of  the  operation  is  rarely  found  necessary. 

Though  it  may  seem  to  be  impossible  at  times  to  place  or  even  start  a  six- 
band  appliance  of  this  character  on  the  teeth  on  account  of  the  disto-mesial  flare 


CHAPTER   LI II.     LABIAL  RETAIXIXG   ILXTLKES 


391 


at  the  occlusal  zone,  yet  in  the  hands  of  an  expert  that  same  appliance  could  be 

readily  placed,  and  in  fact  it  could  be  placed  by  anyone  after  a  little  experience. 

However,  when  it  is  or  seems  to  be  absolutely  impossible  to  place  the  appliance,  as 

sometimes  occurs,  there  is  no  objection  to  sawing  it  in  two  through  the  lingual  section 

of  one  of  the  centrals.    This  will  enable  a  temporary  placing  of  the  separate  pieces 

for  a  few  days,  then  an  impression  is  taken,  etc.,  as  described  for  the  bands,  and  the 

sawed  siu-faces  are  soldered. 

After  the  appliance  has  been  worn  for  about  a  week,  to  aid  the  final  placing, 

it  should  be  removed  and  finished  for  the  permanent  placing.     All  interproximal 

extensions  and  labial  lappings  of  the  incisor  bands  are  cut  down  around  the  contact 

points  to  the  minimum  requirements  for  strength.  The  labial  clips  should  be  allowed 

to  lap  upon  the  teeth  sufficiently  to  hold  them  firmly  in  grasp ;  especially  upon 

teeth  that  have  been  rotated,  and  at  points  where  the  greatest  reactive  force  will 

be  exerted.     After  the  appliance  has  been  worn  for  a  few  months,  or  has  become 

loosened  at  any  point  demanding  its  removal,  the  extent  of  the  laps  may  often  be 

safely  reduced,  so  that  no  more  appears  than  is  often  seen  with  proximal  gold 

fiUings.    See  Fig.  290. 

Removal  of  the  Appliance 

It  is  imperative  that  a  retaining  appliance  be  removed  immediately  upon  the 
discovery  that  any  portion  of  it  has  become  loosened  from  its  cement  attachments 
to  the  teeth,  because  these  loosened  places  serve  as  pockets  for  the  retention  of 
decaying  detritus  which  soon  attacks  and  destroys  the  integrity  of  the  enamel. 

The  need  of  removing  a  retaining 
appliance  intact  for  the  purpose  of 
reattaching  it,  which  is  necessarily 
very  frail  at  its  interproximal  ex- 
tensions, and  which  is  usually  hrmly 
cemented  and  attached  at  nearly 
all  points,  cannot  well  be  accom- 
^T^^i  — •  Z  plished    without    proper    pliers,    to 

say  nothing  of  the  pain  that  would 

be  produced  by  a  free-hand  attempt 
to  lift  or  pull  it  from  its  attachments  to  the  teeth.  This  is  especially  true  of  the 
six-band  labial  retainer.  In  many  instances,  the  plier  shown  in  Fig.  99,  Chapter 
XIX  will  answer  the  purpose,  but  the  one  which  is  especially  adapted  for  this 
part  of  the  operation  is  that  shown  in  Fig.  299. 


Fig.  299 


Restoring  Broken  Interproximate  Extensions 

It  occasionally  happens  with  the  most  careful  handling  that  one  or  more  of  the 
proximal  extensions  will  be  torn  off.  Any  attempt  to  repair  it  by  soldering  the  broken 
edges  together  would  be  futile,  becat:se  of  its  exceeding  thinness  at  this  point,  which 
should  not  be  thickened  with  a  reinforcing  piece  or  overflow  of  solder.    It  can,  how- 


392 


PART   VIII.    RETENTION  IN  DENTAL  ORTHOPEDIA 


Fig.  800. 


ever,  be  very  easily  and  perfectly  restored  in  the  following  manner :  Cut  the  appliance 
nearly  or  quite  in  two  with  a  thin  saw,  by  commencing  at  the 
occlusal  border  and  following  the  proximal  line  marked  by  the 
broken  edge.  Now  place  the  appliance  in  position  on  the  teeth, 
and  form  a  new  T-extension  by  fitting  and  burnishing  to  the  place 
a  piece  of  narrow  thin  banding  material,  which  has  been  doubled 
to  the  form  of  a  T,  as  shown  in  Fig.  300.  An  impression  is  then 
taken  in  plaster  and  the  appliance  removed  with  the  T,  and 
carefully  placed  in  the  impression.  When  this  is  filled  with 
investing  plaster,  the  cast  when  removed  holds  the  T  in  place 
ready  for  soldering.  The  solder  should  be  flowed  between  all 
surfaces  of  the  T  which  lie  in  contact.  Finally,  fit  and  solder 
the  finishing  clip  to  form  the  labial  face  of  the  new  proximal 

extension.    This  when  finished  will  be  quite  as  strong  and  perfect  as  the  original 

piece. 


CHAPTER  LIV 

SUPPLEMENTARY   RETAINING  ATTACHMENTS   AND  APPLIANCES 

In  a  very  large  proportion  of  all  malocclusions,  if  the  six-band  labial  retainer, 
described  in  Chapter  LIII  is  properly  constructed  and  attached,  it  will  be  com- 
monly found  sufficient  in  itself  to  perfectly  retain  the  teeth,  even  though  the 
buccal  teeth  which  have  been  considerably  moved  are  not  involved  in  the  grasp  of 
the  fixture.  This  of  course  presupposes  that  the  upper  and  lower  teeth  have  been 
brought  to  the  desired  relative  positions,  and  that  the  cusps  of  the  buccal  teeth 
perfectly  interdigitate,  though  perhaps  not  in  a  typically  normal  occlusion. 

There  are,  however,  a  number  of  important  supplements  to  this  appliance  which 
will  be  demanded  for  the  retention  of  extensive  movements. 

Retention  of  Lateral  Expansions 

If  one  arch  has  been  laterally  expanded  to  the  desired  occlusion  with  a  normal 
opposing  arch  which  has  not  been  moved,  the  simple  six-band  labial  fixture  will 
usually  retain  the  expansion  and  any  changed  curve  or  malalignment  of  the  labial 
arch.  But  if  the  operation  has  been  performed  without  due  regard  to  the  forces  of 
occlusion  and  the  opposing  arch  has  been  allowed  to  remain  laterally  contracted, 
the  stability  of  these  unmoved  teeth  will  surely  drive  the  expanded  teeth  back  to 
their  former  malpositions.  This  force  of  occlusion  will  frequently  be  sufficient  to  bend 
or  displace  any  labial  retainer  that  is  not  of  unusual  proportions,  and  will  finally 
complete  the  failure  of  the  operation  after  the  retainer  is  removed. 

Fig.  301.  When  both  arches  have  been  laterally  expanded, 

as  they  should  be  in  the  last-named  condition,  if  the 
lower  six-band  retainer  is  reinforced  with  a  clasp 
metal  bow,  No.  17,  soldered  to  the  lingual  face  of  the 
six-band  labial  retainer,  as  shown  in  Fig.  301,  the  forces 
of  occlusion  in  connection  with  the  regular  upper  labial 
retainer,  shown  in  Fig.  290,  will  usually  be  sufficient  to 
~/^  Y^  )    hold  both  arches  in  position. 

With  certain  occlusions  it  may  be  found  expedient 
to  attach  the  lingual  bow  to  the  upper  instead  of  the  lower,  and  in  some  instances 
to  both  arches.  The  length  of  the  arms  and  size  of  the  wire  for  the  lingual  bow  will 
be  governed  by  the  demands  of  the  case.  If  the  distal  area  has  been  much  expanded, 
with  a  demand  that  the  arms  extend  to  the  molars,  they  should  be  supported  by 
thin  lingual  tubes  soldered  to  No.  36  gold  molar  bands,  and  with  ever>'  precaution 
in  finish  for  cleanliness  and  non-irritability. 

393 


394 


PART    VIII.     RETEXTION   IN   DENTAL   ORTIK H'EDf A 


Fig.  302. 


Retention  of  Retruded  Movements 

When  all    of  the  upper  or  the  lower  labial 

teeth    have    been    retruded    to    reduce    decided 

protrusions  and  close  spaces  occasioned  by  the 

extraction  of  premolars,  the  labial  retainer  should 

carry   No.    19   thin  wall  tubes  soldered  to  the 

linguo-distal    borders    of   the    cuspid    bands,    as 

shown  in  Fig.  302,  for  the  purpose  of  attaching 

the  appliance  to  the  molars,  either  at  the  start  or 

upon  the  first  indication  of  a  return  movement. 

The  traction  bars  are  No.  19  or  20  nickel-silver, 

and    usually    should    be    provided    with    mesial 

and  distal  nuts  to  firmly  lock  them  in  the  lingual  tubes  attached  to  gold  molar 

bands.     This  will  enable  one  to  keep  all  interproximate  spaces  closed,  and  if  at 

this  time  the  occlusion  is  perfected  it  will  be  found  sufficient. 

In  many  cases  in  which  the  age  of  the  patient  and  position  of  the  teeth,  etc., 
favor  permanency  of  retention,  the  lingual  bars  and  molar  bands  are  not  at  first 
attached,  though  the  lingual  cuspid  tubes  in  these  cases  should  always  be  placed 
on  the  retainer,  to  be  employed  if  found  necessary.  The  tubes  being  small,  lying 
close  to  the  gum  and  properly  finished,  give  no  irritation  or  annoyance. 


Intermaxillary  Retention 

In  cases  which  are  purely  protrusions  of  the  upper  to  the  extent  that  the  buccal 
cusps  interdigitate  fully  the  width  of  a  premolar  in  front  of  a  normal  occlusion 
(such  cases  being  usually  coiTected  by  the  extraction  of  the  first  or  second  pre- 
molars), the  buccal  teeth  may  be  forced  slightly  forward  of  an  interdigitating  oc- 
clusion if  employed  as  the  sole  anchorage  force  for  retruding  the  labial  teeth,  and 
if  employed  as  the  sole  means  of  retention,  will  tend  to  be  dragged  further  forward 
by  the  reacting  force  of  the  front  teeth.  Or  it  may  be  one  of  the  many  cases  in 
which  the  upper  teeth  in  relation  to  the  lower  teeth  were  protruded — perhaps  to 
the  extent  of  the  full  width  of  a  premolar — but  according  to  dento-facial  rela- 
tions was  found  to  be  due  partially  or  wholly  to 
a  retrusion  of  the  lower  denture,  and  conse- 
quently corrected  without  extraction. 

In  both  of  these  events,  labio-distal  hooks 
should  be  soldered  to  the  labial  retaining  ap- 
pliance as  shown  in  Fig.  303  for  the  purpose  of 
continuing  the  intermaxillary  force. 

The  hooks  are  made  of  No.  28  clasp-metal  or 
round  platinum-gold  wire  soldered  to  the  labio- 
distal  surface  of  the  cuspid  bands,  and  formed  to  protect  the  premolars  from 
the  action  of  the  elastics. 


Fig.  303. 


CHAPTER  LIV.    SUPPLEMENTARY  RETAINING  ATTACHMENTS  395 

In  all  cases  where  the  intemiaxillary  force  has  been  extensively  employed  for 
the  disto-mesial  correction  of  malocclusion,  nothing  but  a  continuation  of  this 
character  of  force,  in  a  milder  degree,  seems  capable  of  retaining  the  position  gained, 
notwithstanding  the  fact  that  the  teeth  at  times  have  been  brought  to  perfect  or 
normal  interdigitating  occlusion.  Moreover,  where  the  final  movements  for  the 
disto-mesial  correction  of  malocclusion  can  be  accomplished  with  the  intermaxil- 
lary force  alone,  the  labial  retainer  may  be  attached  for  this  purpose  as  soon  as  the 
six  front  teeth  are  corrected  in  relation  to  each  other.  This  is  a  most  important 
proposition,  and  one  which  all  orthodontists  will  take  advantage  of  in  those  cases 
where  it  is  indicated,  as  soon  as  they  understand  and  appreciate  the  value  of  a 
properly  constructed  labial  retainer,  because  it  permits  the  early  removal  of  un- 
sightly regulating  apparatus.  It  is  of  special  importance  where  one  or  the  other 
arch  is  decidedly  retruded,  and  the  opposing  arch  but  slightly — if  at  all — protruded, 
as  the  locking  of  the  labial  teeth  together  in  phalanx  in  this  way  increases  their 
stability  opposed  to  movement,  as  in  stationary  anchorages. 

Intermaxillary  Anchorage  Methods  for  Retention 

In  determining  the  character  of  the  opposing  anchorage  appliances  for  applying 
the  intermaxillary  force  for  disto-mesial  movements,  warning  cannot  be  too  often 
repeated  in  regard  to  the  care  that  should  be  exercised  in  the  application  of  a  mesial 
force  through  this  medium,  as  the  same  rules  here  obtain  as  in  major  movements. 
These  are  in  the  main : 

First:    When  no  mesial  or  extruding  movement  of  the  buccal  teeth  is  desired, 

the  anchorage  hooks  for  the  elastics  should  be  placed  at  the  most  distal  points 

possible,  and  attached  to  a  two  or  three-band  stationary  anchorage.   See  Fig.  303. 

Second:     If  a  mesial  force  or  movement  is  de- 
FiG.  304.  .      ,  ,     ,  , .  ,  .     ,         ,       . 

sired,  and  the  extrudmg  tendency  ot  the  elastics 

is  feared,  the  intermaxillary  hooks  should  be  at- 
tached to  the  most  distal  points  of  single  molar 
bands — preferably  to  the  second  molars — which 
are  anchored  down  with  No.  19  or  18  bars,  the 
distal  ends  of  which  rest  in  short  tubes  upon  the  anchor  molars  and  pass  forward 
under  hooks  or  through  short  open-tube  attachments  on  the  first  molars  and  the 
premolars  to  rests  upon  the  cuspids.  See  Fig.  304.  All  of  these  bands  should  be 
as  thin  as  the  desired  strength  will  permit.  With  this  combination,  the  extruding 
force  will  be  distributed  to  all  the  buccal  teeth,  while  a  mesial  tipping  of  the  crowns 
will  be  induced  through  the  possibility  of  the  contact  points  sliding  upon  each 
other.  If  an  arch-bow  is  employed  instead  of  the  bars,  the  incisors  may  also  be 
attached  to  it  if  desired. 

Third:  If  an  extruding  force  or  movement  is  desired,  following  the  correction 
of  a  close-bite  malocclusion  with  apparatus  shown  in  Fig.  197,  the  elastics  should 
be  attached  to  single  first  molar  bands,  or  to  the  crowns  wliich  were  employed  to 


39(5  PARI'    VIII.     RJ'.TEXT/ON   IN   DENTAL   ORIIIOI'liDIA 

Open  the  bite,  and  the  rest  uf  the  apparatus  arranged  to  distribute  the  force  to  the 
premolars. 

Co-operating  with  a  Lower  Labial  Retainer.  In  a  large  proportion  of  cases, 
the  lower  dental  arch   and   malaligned  or  malturned  incisors  which  have  been 

corrected  demand  the  employment  of  a  six-band 

Pip    '\c\\ 

labial  retainer.  In  these  instances  it  is  frequently 
desirable  to  directly  connect  the  retainer  to  the 
intermaxillary  anchorages  which  are  employed 
as  a  retrusive  force  to  the  upper  teeth.  This  will 
afford  a  complete  relief  upoii  the  premolar  area, 
so  that  these  teeth  will  not  be  crowded  out  of  line.  It  is  one  of  the  common  methods 
employed  by  the  author  in  the  mesial  action  of  the  intermaxillary  force  upon  the 
lower  or  upper  arch  when  the  front  teeth  are  in  alignment.  See  Fig.  305.  To  the 
labio-dental  surfaces  of  the  cuspid  bands  of  the  retainer  are  soldered  flattened 
tubes,  which  are  bent  to  receive  the  mesial  ends  of  No.  18  or  19  bars,  the  distal 
ends  of  which  are  locked  with  mesial  and  distal  nuts  in  buccal  tubes  upon  the 
first  molar  bands  or  regulating  crowns.  When  the  intermaxillary  elastics  are  looped 
over  the  distal  nuts  or  attached  to  special  hooks,  the  force  may  be  distributed 
directly  to  the  labial  teeth  in  phalanx.  The  bars  may  also  be  employed  to  correct 
or  retain  the  premolars. 

Reciprocal  Retaining  Action  of  Intermaxillary  Force 

The  most  common  malocclusion  for  which  the  intermaxillary  retainer  is  es- 
pecially applicable  is  that  of  Class  II  in  which  the  upper  buccal  teeth  are  the  width 
of  a  cusp  in  front  of  a  normal  occlusion. 

Where  the  lower  or  upper  front  teeth  have  been  moved  labially  or  lingually 
to  a  considerable  extent,  it  is  presumed  that  the  incisors  have  been  kept  in  an 
upright  position  by  a  bodily  movement.  Upon  removal  of  the  regulating  ap- 
pliances, the  bodily  retaining  apparatus  ( Fig.  310,  described  later),  should  be  attached 
in  connection  with  the  intermaxillary  force. 

The  amount  of  intermaxillary  force  to  be  applied  during  the  period  of  retention 
should  be  governed  by  the  needs  of  the  case.  It  should  not  be  at  any  time  in  ex- 
cess of  a  force  sufficient  to  retain  the  position  gained — that  is  providing  the  teeth 
are  fully  corrected  when  the  retainer  is  placed — as  this  would  necessitate  stopping 
the  force  every  once  in  a  while  and  allowing  the  teeth  to  go  back,  and  it  is  this  swing- 
ing back  and  forth  in  the  sockets  that  is  especially  opposed  to  the  formation  and 
solid  fixation  of  a  permanent  retaining  alveolus.  It  is  far  more  advisable  that  the 
heft  of  the  elastics  be  gauged  to  the  required  degree  of  force,  to  hold  the  teeth  per- 
fectly so  that  the  elastics  can  be  worn  continuously. 

Faber  No.  5  (Ticket  Rings)  are  the  same  size  in  circumference  but  only 
about  one-half  the  heft  of  No.  6  (Election  Rings).  The  latter,  single  and  double, 
are  commonly  used  for  regulating.     No.  7   (Thread  Bands)  are  the  same  heft 


CHAPTER  LIV.     SUPPLEMENTARY  RETAINING  ATTACHMENTS  397 

as  No.   6,   but   being  about  twice  the  size,  will  exert   less  intermaxillary  force 
than  No.  5. 

After  correcting  the  labial  malrelations  of  the  arches  and  placing  the  front  teeth 
in  proper  arch  alignment,  the  author  frequently  places  the  retaining  apparatus 
shown  in  Fig.  305,  before  the  disto-mesial  malocclusion  is  wholly  corrected,  knowing 
that  the  intermaxillary  force  can  be  gauged  to  any  degree,  and  will  if  properly 
applied,  act  quite  as  perfectly  in  retaining  or  moving  the  teeth  as  with  the  regu- 
lating apparatus.  The  teeth  are  not  so  liable  to  be  forced  out  of  alignment,  and 
the  appliance  is  far  less  conspicuous  than  the  usual  regulating  appliance;  more- 
over, the  rigidity  of  the  retainer,  holding  the  labial  curve  of  the  arch  in  its 
corrected  position,  is  of  the  greatest  aid  in  preventing  the  reactive  forces  from 
laterally  contracting  the  entire  arch. 

Direct  Intermaxillary  Retention 

The  correction  of  extensive  open-bite  malocclusions  has  always  been  more 
difficult  to  retain  than  any  other  character  of  irregularity,  because  of  the  impos- 
sibility in  most  cases  of  obtaining  a  stable  hold  upon  which  to  anchor  a  retainer 
that  would  successfully  combat  the  force  of  reaction.  If  a  lingual  or  labio-buccal 
bow  is  anchored  to  the  molar  teeth  for  this  purpose,  the  reactive  forces  of  the  origi- 
nally open-bite  labial  teeth  will  usually  force  the  distal  extremities  of  the  bow  and 
anchorages  in  the  opposite  direction,  extruding  the  molars,  which  in  itself  will 
open  the  bite  still  further,  as  any  movement  at  this  point  will  be  magnified  in  its 
action  upon  the  front  teeth.  The  intermediate  teeth  which  are  also  employed  in 
this  method  as  fulcrums  to  the  elastic  force  of  the  bow  are  frequently  intruded. 

Pjg  3QP,  These  difficulties  are  now  overcome  by  soldering  small 

spurs  to  the  upper  and  lower  labial  retainers,  as  shown  in 
Fig.  306.  To  these  the  patient  attaches  direct  intermaxil- 
lary elastics,  which  are  worn  continuously  at  all  times  that 
do  not  interfere  with  required  ftmctions.  This  force  should 
be  continued  until  the  forces  of  reaction  are  completely 
overcome. 
As  a  large  proportion  of  these  cases  are  mouth-breathers  at  the  time  of  the 
operation — the  habit  having  continued  long  after  the  causes  are  removed — 
the  elastics  also  subserve  the  purpose  of  aiding  the  patient  in  overcoming  this 
unhealthful  habit.  Fig.  307  illustrates  a  common  open-bite  malocclusion  which 
was  principally  corrected  with  the  retaining  apparatus  as  shown. 

Occipital  Retention 

In  the  correction  of  many  cases  of  decided  upper  protrusions,  especially  those 
in  which  the  incisors  are  in  an  extruded  position  and  thus  in  unpleasant  evidence 
in  relation  to  short  upper  lips,  and  particularly  when  complicated  with  close-bite 
malocclusions,  the  occipital  force  with  its  upward  and  backward  direction  of  move- 


398  /MA'/'    VIII.     RETENTION   IN   DENTM.   OKTIJOJ'EDIA 

ment  has  proven  im  indispensable  auxiliary  in  the  author's  practice.  Aj^ain,  in  the 
correction  of  open-bite  malocclusions  complicated  with  lower  protrusions  (Division 
4,  Class  Til ),  the  occipital  force,  throut^di  the  medium  of  the  lower  occipital  bow  is 

Fig.  307. 


one  of  the  most  valuable  and  effective  forces  for  closing  the  bite  and  aiding  the 
retrusive  movement  of  the  lower  labial  teeth  after  the  extraction  of  premolars. 
(See  Occipital  Force,  Chapter  XVI.) 

Fig.  uns.  In  both  of  these  characters,  the  tendency  of  the  re- 

active forces  are  often  difificult  to  overcome  for  a  time  with 
dental  retainers  alone.  Nor  does  one  always  obtain  the 
full  desired  results  of  these  movements  at  the  time  when 
the  case  is  otherwise  corrected  and  ready  for  the  usual  retaining  appliances.  In 
these  cases,  therefore,  a  platinum-gold  wire,  size  .040",  is  soldered  to  the  inter- 
proximal extensions  of  the  six-band  labial  retainer,  and  in  such  a  position  as  to 
span  the  central  incisors,  as  shown  in  Fig.  308.  The  bar  which  crosses  well  above 
the  median  T-extension  of  the  appliance  forms  a  perfect  rest  for  the  occipital  bow 
A  on  the  upper,  and  bow  B  on  the  lower.  Small  rings  soldered  to  the  bar  on  each 
side  of  the  lips  of  the  rest  prevent  lateral  motion. 

The  occipital  apparatus,  worn  at  night,  with  a  moderate  degree  of  force  will 
give  little  or  no  annoyance,  and  will  exert  an  evenly  distributed  force  upon  all  the 
labial  teeth  to  which  the  retainer  is  attached.  In  the  many  cases  for  which  it  has 
been  employed  in  this  way,  it  has  accomplished  results  that  the  author  believes 
wotdd  have  been  otherwise  impossible. 

Retention  of  Bodily  Movements 

In  the  contemplation  of  retaining  teeth  which  have  been  moved  bodily,  the 
magnitude  and  peculiarity  of  the  force  of  a  lever  of  the  third  kind,  which  is  the 
active  mechanical  principle  in  the  bodily  movement,  is  equally  important  to 
consider  when  we  come  to  the  retention  of  this  movement. 

The  retaining  appliance  capable  of  fully  sustaining  this  movement  must  be 
one  that  will  forcibly  combat  the  great  reacting  tendency  of  the  elastic  bone  and 
tissue  fibers  to  return  to  equilibrium.  As  this  force  is  exerted  along  the  entire 
length  of  the  root,  it  must  be  seen  that  the  stress  upon  the  comparatively  narrow  zone 
of  the  crown  which  is  grasped  by  the  retaining  appliance  increases  as  the  force  ap- 
proaches the  apical  end  of  the  root,  on  the  same  principle  that  the  advantage  of  a 


CHAPTER  LIV.    SUPPLEMENTARY  RETAINING  ATTACHMENTS 


399 


Fig.  309. 


lever  of  the  first  kind  is  increased  by  lengthening  the  power  arm.  Therefore,  the 
necessity  is  apparent  in  this  character  of  retention  of  employing  distally  extended 
arms  with  stable  attachments  to  the  retainer.  This  is  especially  true  of  bodily 
labial  movement  of  the  front  teeth  which  so  commonly  carries  the  entire  alveolar 
ridge  forward  in  a  manner  that  could  not  be  accomplished  other  than  by  bending 
and  stretching  the  cancellous  structure  of  the  alveolar  process  at  the  apical  zone 
of  its  attachments.  With  bodily  retruding  movements  of  the  labial  teeth,  the  ob- 
structing alveolar  process  in  the  pathway  of  the  moving  roots  is  to  a  very  large 
extent  resorbed,  and  consequently  they  are  far  more  easily  retained.. 

When  a  bodily  protruding  or  retruding  move- 
ment of  the  incisors  has  been  produced  and  has 
not  been  accompanied  by  a  movement  of  the 
roots  of  the  cuspids,  the  six-band  labial  re- 
tainer, attached  firmly  as  it  is  to  the  cuspid 
teeth,  will  greatly  aid  in  retaining  the  root 
movement  of  the  incisors,  though  it  should 
always  be  .supplemented  with  lingual  bars  to 
the  molars.  Fig.  309  represents  the  common 
retainer  employed  in  these  cases.  Resilient 
clasp-metal  or  platinum-gold  (.032")  bars  are 
closely  fitted  into  long-bearing  elliptical  clasp- 
metal  tubes  which  are  soldered  to  the  lingual  surfaces  of  the  regular  six-band 
retainer.  The  bars  rest  in  lingual  molar  open-tube  attachments,  with  lock-nuts  to 
insure  stability.  In  the  final  assembling  and  placing  of  the  appliance,  the  bars  are 
bent  up  or  down  so  that  when  sprung  into  the  tubes  they  will  exert  a  slight  extra 
force  upon  the  roots  in  the  direction  of  their  movement.  Then  the  anchorage  tubes 
are  closed  around  the  bars  and  the  projecting  edges  and  corners  are  smoothed  to 

prevent  irritation  of  tissues.  In  addition 
to  retaining  the  teeth,  the  forces  of  move- 
ment may  be  increased  by  bending  the  bars 
and  turning  the  nuts. 

Where  extensive  bodily  labial  move- 
ments have  been  accomplished,  the  bands 
of  the  labial  retainer  should  be  sufiiciently 
wide  to  cover  the  entire  lingual  surfaces 
to  which  they  are  perfectly  fitted,  in  order 
to  produce  a  wide  and  perfect  grasp  upon 
the  crowns.  When  resilient  bars  are  firmly 
attached  to  these  long-bearing  bands,  and 
the  ends  sprung  into  open-tube  attach- 
ments on  the  molars,  they  exert  a  push  force  at  the  gingival  zone  which  is  transmitted 
to  the  entire  root.    In  connection  with  this,  if  the  ends  of  the  bars  are  threaded 


Fig.  310. 


•100  IWRT    VIII.     RETE\"riO\    l\    DENTAL  ORTIIOI'EDLl 

for  niesially  aclinsj;  nuts,  the  appliaiu-c  can  be  made  to  exert  a  similar  though  less 
])owerfuI  force  to  that  of  the  rej^ular  contour  apparatus.  Sec  I'^i.g.  310.  Because 
of  its  inconspicuousncss,  it  may  be  preferably  employed  as  a  worlcing  retainer 
from  the  start  in  minor  bodily  protruding  movements  of  the  incisors.  In  all  cases 
where  it  seems  desirable  to  remove  the  regular  apparatus  before  the  full  completion 
of  its  work,  it  will  be  found  invaluable  for  holding  the  position  gained,  and  for 
continuing  the  movement.    This  apparatus  is  described  as  follows: 

The  Working  Bodily  Movement  Retainer,  shown  in  Fig.  310,  is  designed  to 
retain  extensive  Ixjclily  labial  m(_)vements  ior  the  older  class  of  patients;  the  lingual 
bars  being  much  larger  than  those  usually  employed.  (See  Chapter  XX.)  It  is 
constructed  with  a  view  to  combat  the  reaction  of  extensive  root  movement; 
also  to  continue  this  force,  and  if  necessary  the  bodily  movement  to  a  lessened 
degree.  To  the  lingual  surfaces  of  tlie  lal')ial  retainer  (upper  or  lower)  is  soldered 
a  nickel-silver,  or  preferably  platinum-gold  wire  bow  (.045"  or  .040"),  threaded 
at  the  ends  for  mesial  nuts.  The  contact  surfaces  of  the  bow  are  filed  to  fit  the 
lingual  surfaces  of  the  appliance  before  soldering.  When  smaller  resilient  bars  are 
employed,  it  is  important  that  their  spring  temper  should  not  be  removed  in  the 
soldering  process,  especially  if  they  are  of  nickel-silver.  A  favorite  method  of  the 
author's  is  to  use  elliptical  gold-platinum  tubing  for  the  attachments,  which  are 
soldered  to  the  usual  lingual  reinforcement  plate.  The  distal  ends  of  the  bars  are 
threaded  to  lie  in  open  lingual  tubes  upon  the  molar  anchorages  which  are  also 
provided  with  buccal  intermaxillary  hooks.  The  same  care  should  be  exercised 
in  fitting  the  bow  or  bars  to  lie  along  the  lingual  surfaces  of  the  teeth,  and  the  ends 
to  lie  evenly  in  the  tubes,  as  was  described  in  fitting  the  power  bow  in  the  regular 
contour  apparatus.  Finally,  with  this  apparatus  the  ends  of  the  bow  or  bars  are  bent 
at  the  points  where  they  join  the  labial  retainer  toward  the  occlusal  plane,  so  that 
in  the  final  assembling,  after  the  cement  has  hardened,  the  ends  are  sprung  toward 
and  into  the  open  tubes  which  are  then  closed  around  them.  The  distal  ends  of 
the  tubes  and  bow  should  be  beveled  and  finished  to  present  no  irritating  surfaces. 

Fig.  311  is  presented  to  illustrate  diagram- 
;'  '"P*  matically  the  action  of  the  lingual  retaining 
bars.  The  premolars  are  removed  from  the 
drawing  to  show  the  lingual  bars.  The  dotted 
lines  and  arrows  indicate  the  principles  of 
action.  It  will  be  observed  that  the  spring 
of  the  bars  in  combination  with  the  rigidly 
attached  labial  retainer  is  calculated  to  exert  a  bodily  labial  force  upon  the  roots. 
This  force  will  be  in  proportion  to  the  amount  of  bend  that  is  given  to  the  bars  in 
the  final  placing,  while  the  labial  force  will  be  otherwise  controlled  by  the  nuts 
at  the  mesial  ends  of  the  tubes.  If  at  any  time  it  is  desired  to  increase  or  reduce 
the  force  upon  the  roots  of  the  labial  teeth,  the  bars  can  be  easily  bent  with  the 
curved  wire  benders  shown  elsewhere.    The  intermaxillary  force  is  an  important 


CHAPTER  LIV.     SUPPLEMENTARY  RETAINING  ATTACHMENTS  401 

auxiliary  in  sustaining  the  stability  of  the  anchorages  and  as  an  aid  toward  a  general 
protrusive  movement  of  the  upper  teeth  and  rctrusive  movement  of  the  lower. 

When  this  apparatus  is  employed  principally  for  bodily  labial  movement  of 
the  incisor  teeth — as  it  may  be  in  all  minor  cases — with  the  view  of  forcing  the 
cuspids  and  first  premolars  forward  by  inclination  movement  with  push  bars  from 
the  anchorages,  or  with  the  production  of  a  mesial  movement  of  all  of  the  buccal 
teeth  with  the  intermaxillary  force — the  incisors  should  first  be  placed  in  relative 
alignment  and  the  four-band  labial  retainer  should  be  constructed  with  the  lingual 
bow  attached,  etc.,  as  described  above.  If  the  cuspids  and  first  premolars  are  to 
be  moved  forward  with  the  view  of  inserting  artificial  premolars  to  sustain  the  arch, 
buccal  tubes  should  be  soldered  to  the  anchorages  for  No.  .040"  push  bars  to  be 
employed  for  this  purpose  later  in  the  operation. 

The  author  was  pleased  to  have  Dr.  Angle  take  advantage  of  this  invention  in 
the  presentation  of  his  pin  and  tube  "working  retainer"  in  1910,  the  mechanical 
principles  of  which  are  exactly  the  same  as  that  which  was  published  and  illustrated 
as  above  in  the  first  edition  of  this  work.  The  difterence  being  that  he  obtained 
bodily  force  action  through  the  torsional  spring  of  a  very  small  labial  arch-bow 
instead  of  the  direct  spring  of  lingual  bars.  His  employment  of  this  principle  in  his 
practice  no  doubt  led  to  his  appreciation  and  sudden  enthusiastic  acceptance  of  the 
possibilities  and  value  of  bodily  movement,  which  resvilted  in  his  applying  this 
pin  and  tube  method  to  regulating  appliances,  etc.,  and  now  to  the  general  accept- 
ance of  the  great  value  of  the  bodily  movement  of  teeth. 

Permanent  Retaining  Fixtures 

In  most  cases  where  the  teeth  have  been  properly  corrected,  and  a  perfect 
retaining  appliance  has  been  subsequently  worn  for  two  years,  with  the  attention 
that  should  be  given  to  it,  the  positions  of  the  teeth  will  not  materially  change.  It 
unfortunately  is  a  fact  that  occasionally  after  a  perfect  and  seemingly  adequate 
retention,  there  are  instances  in  which  the  teeth  when  unrestrained  will  move  more 
or  less  back  toward  their  former  malpositions. 

As  it  is  impossible  to  determine  in  each  case  the  absolute  time  that  a  fixture 
should  be  worn  to  insure  permanency  of  retention,  it  has  been  the  author's  custom 
to  insist  upon  keeping  the  appliance  on  the  teeth  mvich  longer  than  would  ordi- 
narily seem  necessary.  As  a  result  of  experience  in  this  department,  the  time  limit 
for  wearing  retaining  fixtures  has  gradually  lengthened  in  the  last  twelve  years, 
from  about  six  months  to  two  years;  and  in  some  instances  of  marked  inherited 
irregularities,  they  are  now  worn  three  years. 

As  the  need  of  lengthening  the  retaining  period  has  developed,  it  has  called 
for  a  gradually  increasing  perfection  of  retaining  appHances  to  avoid  injuring  the 
teeth,  and  to  present  an  acceptable  appearance.  The  need  of  such  an  appliance 
produced  the  retaining  fixtures  and  methods  described  in  the  two  previous  chapters. 
It  now  remains  to  describe  a  final  method  of  retention  for  the  treatment  of  those 


402 


PART    VIII.     RETENTION  IN   DENTAL   ORTIIOPEDIA 


comparatively  few  cases  which  demand  a  permanent  fixture,  or  at  least  one  that 
will  need  to  be  worn  many  years,  indeed  too  long  to  ask  a  patient  to  keep  in  the 
mouth  an  appliance  that  in  any  way  mars  the  natural  appearance  of  the  teeth,  to 
say  nothing  of  the  increased  danger  to  the  teeth  that  is  caused  by  cemented  bands 
worn  during  long  periods. 

The  most  conspicuous  of  the  irregularities  which  demand  a  permanently  attached 
fixture  is  that  which  is  characterized  by  abnormal  interproximate  spaces  be- 
tween the  upper  incisors,  most  frequently  found  between  the  central  incisors,  and 
which  are  commonly  impossible  to  retain  without  a  permanent  fixture.  This  charac- 
ter of  irregularity  is  fully  described  and  illustrated  in  Chapter  L,  where  the  causes 
and  treatment  will  be  found  with  specific  methods  of  correction. 

The  teeth  which  assume  this  special  irregularity  present  the  most  continued 
opposition  to  retention  after  correction  of  any  of  the  malpositions,  even  though  the 
apparent  local  cause  be  wholly  removed.  In  a  number  of  instances  of  this  character, 
which  were  perfectly  retained  for  two  years,  upon  removal  of  the  retainer,  the  teeth 
soon  showed  signs  of  returning  to  their  former  malposition  and  with  no  apparent 
cause  for  it  other  than  the  unaccountable  forces  of  nature.  Therefore,  if  we  hope 
to  correct  this  irregularity  which  frequently  mars  perfect  enunciation,  and  is 
conspicuously  unpleasant  in  appearance,  the  proposition  of  permanent  retention 
must  be  considered.  Any  form  of  band  retainer  is  objectionable,  because  of  its 
appearance  and  possible  injury  to  the  teeth. 

The  retainer  which  the  author  has  employed  with  the 
greatest  satisfaction,  where  the  space  is  between  the  centrals, 
is  in  the  form  of  a  staple,  which  doubtless  has  been  used  for 
years  in  various  forms  and  positions.*  When  constructed 
according  to  the  methods  here  proposed,  and  properly  placed 
in  position,  it  is  seen  only  upon  the  lingual  aspect  as  a  flattened 
gold  bar  which  extends  from  the  lingual  fossa  of  one  tooth 
to  the  other,  formed  and  finished  to  present  the  least  possible 
obstruction  and  irritation  to  the  tongue.    See  Fig.  312. 

This  may  be  made  of  gold  wire  No.  16.  The  ends  are 
bent  at  right  angles  at  the  proper  distance  apart,  and  filed 
down  to  enter  No.  19  holes  bored  in  the  teeth,  as  will  be 
described.  The  No.  16  wire  is  of  sufficient  size  to  permit  bevel- 
ing the  bar  to  fit  the  beveled  borders  of  the  holes,  marginal  ridges  of  the  teeth,  and 
conform  to  the  interproximal  gingivae.  The  exposed  or  lingual  surface  of  the  bar 
is  also  beveled  in  a  line  with  the  plane  of  the  enamel  surfaces  and  finished  to  present 
no  greater  prominences  than  demanded  for  strength. 

A  staple  retainer  of  this  character  was  constructed  for  one  of  Dr.  Thos.  L. 
Gilmer's  patients  in  1894,  since  which  time  it  has  been  worn  without  removal, 


Fig,  312. 


'Presented  at  the  meeting  of  the  Odontological  Society,  April,  1903,  and  pubUshed  in  the  Dental  Review,  Feb- 
ruary, 1904. 


CHAPTER  LIV.    SUPPLEMENTARY  RETAINING  ATTACHMENTS 


403 


and  with  no  perceptible  change  or  injury  to  the  teeth.  This  is  shown  in  Fig.  313. 
The  two  casts  on  the  left  are  before  and  after  correction.  That  on  the  right  is  from 
an  impression  taken  over  ten  years  afterward  with  the  appliance  on  the  teeth. 


Fig.  313. 


Fig.  314. 


The  late  Dr.  Joseph  Wassail  suggested  a  very  practical  modification  in  the  tech- 
nic  construction  of  this  retainer,  especially  applicable  when  employed  to  retain 
more  than  two  teeth.    When  the  pits  in  the  teeth  are  prepared,  by  boring  all  the 

holes  exactly  parallel,  place  in  them  straight  short 
posts  of  No.  19  gold  wire  and  take  a  plaster  im- 
pression. To  insure  pulling  the  posts  out  of  the 
pits  with  the  impression,  they  may  be  roughened, 
or  the  projecting  ends  bent.  When  the  impression 
is  filled  with  investing  material,  and  carefully 
separated  so  as  to  avoid  dislodging  the  posts  from 
the  model,  it  will  enable  one  to  solder  to  them  the 
spanning  bar.  After  this  the  surplus  projecting 
ends  are  cut  away,  and  the  appliance  finished  and 
placed  as  before.  Fig.  314  shows  an  appliance 
of  this  kind  placed  in  a  position  to  be  forced  to  its  final  seating  for  uniting  the  cen- 
trals and  cuspids. 

The  spanning  bar  should  be  shaped  to  conform  to  the  line  of  lingual  ridges  of 
the  teeth  and  gingivae  over  which  it  rests,  being  careful  that  it  freely  spans  the 
median  interproximate  gingivae,  as  any  pressure  upon  the  tissue  at  this  point  will 
cause  inflammation  and  swelling.  Moreover,  there  should  be  no  attempt  to  make 
it  fit  accurately  to  the  teeth,  as  might  be  accomplished  by  grinding  grooves  in  the 
marginal  ridges.  In  fact,  it  would  be  better  to  leave  the  under  surface  of  the  bar 
rounded  and  sufficiently  free  from  the  enamel  to  allow  the  removal  of  accumula- 
tions, with  dental  floss,  etc.  In  fitting  the  bar  on  the  model,  place  it  at  one  side  of 
the  projecting  posts,  either  occlusally  or  gingivally  as  seems  best  to  meet  the  re- 
quirements and  avoid  occlusal  contact,  or  separate  bars  may  be  fitted  between  the 
posts. 

By  making  a  labio-lingual  section  of  a  central  incisor,  as  shown  in  Fig.  315, 
it  will  be  found  that  the  thickness  and  shape  of  the  hnguo-cervical  wall  will  safely 


404 


PART    I  in.     RETEMION   IN   DENTAL  ORT/IOl'EDIA 


permit  the  boring  of  a  hole  of  suffieient  size  and  depth,  if  started  in  a  line  with  the 
middle  of  the  wall  and  carried  parallel  to  the  central  axis  of  the  tootli. 

The  location  and  direction  of  the  proposed  hole  can  easily  be  determined .  by 
the  eye.    In  gazing  root-wise  at  a  labial  tooth,  take  such  a  position  as  will  bring 


Fir,,  -.v,:. 


the  cutting  edge  exactly  in  the  center  between  the  gingivo-labial  and  gingivo- 
lingual  borders  of  the  crown,  and  you  will  be  looking  directly  along  the  line  of  the 
central  axis  of  the  tooth. 

Use  a  No.  19  drill  and  start  the  hole  in  the  lingual  fossa  at  a  point  whose  line 
of  direction,  parallel  to  the  central  axis,  will  leave  sufficient  body  on  the  lingual 
side  of  the  pit,  and  then  bore  to  the  depth  of  about  three  millimeters.  In  a  typi- 
cally formed  central  incisor  of  ordinary  size,  the  thickness  of  the  linguo-gingival 
wall  is  about  three  millimeters  to  the  depth  of  at  least  six  milHmeters.  The  diam- 
eter of  a  No.  19  drill  is  about  .035  of  an  inch.  One  millimeter  is  over  .039  of  an 
inch.  Consequently,  if  the  proper  course  is  pursued,  you  are  safely  one  millimeter 
from  either  wall.  The  holes  should  be  perfectly  parallel  with  each  other  as  before 
stated,  with  margins  very  slightly  countersunk,  and  no  larger  than  demanded  to 
closely  fit  the  posts. 

The  safety  and  continued  permanency  of  this  form  of  appliance  lies  in  the 
fact  that  the  holes  can  be  bored  without  injury  to  the  adjoining  enamel.  But  no 
attempt  should  be  made  to  cover  in  the  surrounding  enamel  surfaces  with  small 
pieces  of  plate  or  washers,  however  accurately  they  may  be  fitted,  because  the 
intervening  cement  will  soon  wash  out  and  leave  pockets  for  decaying  detritus 
which  will  ultimately  cause  decay  of  the  teeth.  On  the  contrary,  the  bar  where  it 
leaves  the  pins  and  passes  over  the  marginal  ridges  should  lie  upon  the  natural 
enamel  surfaces  with  free  rounded  contact  so  as  to  permit  perfect  cleansing. 

One  is  occasionally  called  upon  to  treat  patients  older  than  twenty-five  years 
of  age  with  protruding  upper  incisors,  having  wide  interproximate  spaces  between 
the  centrals  and  at  times  between  all  of  the  labial  teeth  which  are  not  caused  or 
held  in  that  position  by  the  occlusion  of  the  lower  teeth. 

There  should  be  no  hesitation  in  regard  to  correction  in  these  cases,  even 
though  the  apparent  cause  is  pyorrhea.  In  fact,  with  proper  preUminary  treatment, 
nothing  will  tend  more  favorably  to  throw  off  the  dormant  conditions  of  pyorrhea 
and  restore  health  than  the  required  movement  of  the  teeth.     In  many  instances, 


CHAPTER  LIV.    SUPPLEMENTARY  RETAINING  ATTACHMENTS  405 

the  irregularity  may  have  arisen  from  inherent  tendencies,  or  from  the  thumb- 
sucking  habit,  which  forced  the  deciduous  and  permanent  labial  arch  forward. 
In  any  event  there  seems  to  be  no  accounting  for  that  continued  wide-spaced  mal- 
position of  the  incisors  opposed  constantly  and  perhaps  from  the  time  of  their 
eruption,  by  the  contruding  force  of  the  lips. 

If  the  cuspids  are  not  involved  in  the  protruded  condition,  and  if  after  the 
lingual  movement  of  incisors  they  will  not  retain  their  position,  even  after  having 
been  held  perfectly  with  the  labial  retainer  for  two  years — they  can  be  surely  and 
safely  retained  with  the  permanent  retaining  fixture.  This  may  at  times  be  attached 
only  to  the  cuspids  and  central  incisors.  The  fact  that  it  is  completely  out  of 
sight  and  can  be  easily  removed  at  any  time,  and  the  small  holes  filled  with  gold, 
makes  this  form  of  retainer  superior  to  the  six-band  appliance  in  all  cases  of  this 
character  which  require  very  long  or  permanent  retention.  In  those  cases  in  which 
it  is  applicable,  and  which  seem  to  demand  a  permanent  fixture,  and  also  those 
which  indicate  the  need  of  retention  an  unusual  length  of  time,  this  method  is  the 
only  one  employed  by  the  author. 

In  recommending  this  appliance,  which  doubtless  will  appeal  to  many  because 
of  its  apparent  simplicity  and  ease  of  construction,  it  is  hoped  that  a  careful  and 
skillful  application  of  the  rules  laid  down  for  boring  and  preparing  the  holes  will 
be  closely  observed.  This  is  by  far  the  most  important  part  of  the  operation. 
The  next  is  in  the  accuracy  of  fittings  at  the  margins  of  the  holes.  The  bars  should 
conform  somewhat  to  the  shape  of  the  surfaces  over  which  they  lie,  and  take  the 
position  best  calculated  for  freedom  from  the  tongue  and  lower  teeth.  This  can  be 
accomplished  on  the  model  preparatory  to  soldering  to  the  pins;  the  final  adjust- 
ments to  correct  slight  imperfections  being  made  at  the  chair  preparatory  to  cement- 
ing the  completed  fixture. 


PART   IX 


The  Prosthetic  Correction  of  Cleft  Palate 


THE  PROSTHETIC  CORRECTION  OF 
CLEFT  PALATE 


CHAPTER  I 

GENERAL  PRINCIPLES  IN  THE  MECHANISM  OF  SPEECH,  AND  THE  TRAINING 
OF   CLEFT   PALATE   PATIENTS   AFTER  OPERATION 

In  taking  up  the  sttidy  of  correction  of  Cleft  Palate,  the  student  is  referred  to 
any  one  of  the  main  works  upon  Oral  Surgery  for  the  history,  the  etiology,  and  the 
peculiar  physical  and  anatomic  characteristics  of  this  unfortunate  deformity. 

For  the  purposes  of  our  present  work  which  pertains  purely  to  the  practical 
correction  of  speech  by  prosthesis,  for  cleft  palate  patients,  the  student  should  fully 

Fig.  1. 


A  typical  single  cleft  of  the  palate.  The  dotted  line  shows 
the  border  should  not  extend  back  of  the  most  anterior 
attachment  of  the  velum-palati. 

reahze  at  the  outset  that  the  real  object  of  a  cleft  palate  operation,  whether  by 
surgery  or  prosthesis,  is  to  fully  restore  the  deficient  parts  in  a  manner  that  will 
enable  the  muscles,  in  connection  with  the  restoration,  to  perform  all  the  functions 
of  normal  speech,  so  that  the  patient  will  be  able,  with  proper  training,  to  speak 
with  perfect  articulation  and  normal  voice  tone  quality. 

One  cannot  appreciate  the  many  requirements  that  are  demanded  of  an  arti- 
ficially or  a  surgically  restored  palate  until  he  fully  understands  the  normal  mecha- 

409 


410  yMA'7'   JX.     THE  PROSTHETIC  CORRECTION  OF  CLEFT  PALATE 

nism  of  speech  and  the  main  principles  of  phonology,  and  particularly  the  part 
whicli  is  ])la\-e(l  l)y  the  velum-palati,  whose  function  is  destroyed  Vjy  the  cleft. 
This  knowledge  is  quite  as  important  in  our  college  teaching  in  pointing  the  way 
to  the  successful  treatment  of  cleft  palate,  as  it  is  to  teach  that  occluso-prox- 
imate  fillings  in  dentistry  are  for  something  more  than  closing  the  cavity  in  the 
tooth,  and  why  the  really  successful  operation  demands  the  restoration  of  anatomic 
form  and  contact  contours  which  nature  has  found  imperative  for  the  preser- 
vation of  masticating  occlusion  and  the  future  healthfulness  of  interproximate 
tissue.  If  these  imperative  foundation  principles  were  not  taught  in  the  operative 
departments  of  our  dental  colleges,  what  hope  would  there  be  for  the  future  success 
of  our  graduates  in  practice? 

After  operations,  proper  intelligent  instruction  in  the  art  of  speaking  cor- 
rectly is  quite  as  important  to  cleft  palate  patients  as  the  operation  itself.  In 
regard  to  this  it  is  a  pleasure  to  quote  from  the  late  Dr.  G.  Hudson-Makuen,* 
whose  extensive  experience  in  the  teaching  of  cleft  palate  pupils  to  speak,  renders 
his  opinion  of  the  greatest  value.  In  speaking  of  the  comparative  value  of  training 
pupils  to  speak  before  and  after  surgical  operations,  he  says: 

"In  the  adolescent  or  adult  cleft  palate  patient,  traiiiiiig  ic///  do  more  for  tlie 
improvement  of  speech  than  .will  the  surgical  operatio)i.  In  other  words,  a  patient 
who  can  have  the  advantage  of  but  one  of  the  two  procedures  can  probably  be 
given  better  speech  by  training  alone  than  by  a  surgical  operation  alone.  The  reason 
for  this  is  apparent  when  we  consider  the  limitations  of  the  operation.  In  the  first 
place,  the  speech  as  I  have  shown,  is  defective  in  three  important  particulars, 
namely,  in  resonance,  in  melody,  and  in  articulation.  The  extent  to  which  we  can 
improve  the  resonance  and  melody  of  the  voice  by  the  mere  closure  of  the  cleft 
[with  a  surgical  operation]  is  very  slight,  because  however  well  the  operation 
may  be  done,  the  patient  will  have  but  limited  control  of  a  more  or  less  tense  velum, 
and  he  will  be  unable,  therefore,  to  regulate  the  size  of  the  openi'ng  between  the 
oro-pharynx  and  the  naso-pharynx.  .  .  .  Moreover,  the  rapid  changes  in 
pitch  which  result  in  the  so-called  melody  of  the  voice  cannot  be  made  with  any 
degree  of  accuracy,  because  the  function  of  the  palato-pharyngeal  muscles,  which 
have  their  lower  attachments  in  the  superior  comua  of  the  thyroid  cartilage  of  the 
larynx,  is  at  least  partially  destroyed  by  the  cicatricial  contractions  which  follow 
the  operation,  and  by  the  atrophy  which  has  taken  place  from  the  disuse  of  these 
muscles  before  the  operation  was  performed." 

This  concisely  expresses  the  truth  in  regard  to  the  value  of  nearly  all  surgical 
operations  for  the  correction  of  cleft  palate  when  operated  upon  after  early  infancy, 
and  it  also  applies  to  a  very  large  proportion  of  the  infantile  operations. 

There  is  one  very  important  thing  which  he  does  not  mention:  It  is  only  in 
very  rare  cases  of  cleft  palate  at  three  years  of  age  that  there  is  a  sufficient  length 
of  soft  palatal  tissue — when  the  borders  of  the  cleft  are  brought  together  and  per- 

*  "Oral  Surgery,"  Dr.  T.  W.  Brophy,  Chap.  XXX. 


CHAPTER   I.     GENERAL   PRIXCIPLES 


411 


fectly  united — to  close  the  oro-nasal  passage,  and  after  that  age,  with  or  without 
an  operation,  this  lack  of  palatal  tissue  increases  until  adult  life,  because  of  a 
lack  of  functional  growth  development. 

A  recognition  of  the  necessity  for  a  more  complete  closure  of  this  passage  in 
fulfillment  of  the  demands  of  perfect  speech  has  led  many  skillful  surgeons  to 
the  performance  of  quite  wonderful  plastic  operations  in  lengthening  the  velum 
with  the  view  of  enabling  it  to  properly  functionate  as  an  organ  of  speech.  In 
regard  to  these  more  extensive  operations  it  is  unfortunate  but  true  that  the  greater 
the  extent  of  the  operation,  the  greater  is  the  functional  destruction  of  important 
muscular  tissue  for  the  necessary  surgical  building,  with  a  proportional  amount  of 

Fig.  2. 


The  above  illustration  was  made  from  the  models  of  a  case  which  originally  was  a  typical  cleft 
with  plenty  of  normal  palatal  tissue,  but  now  is  a  wide  cleft  with  cicatricial  remnants  of  the 
soft  bifurcated  palate,  after  several  frantic  attempts  had  been  made  to  close  the  cleft  surgi- 
cally.    On  the  right,  is  seen  the  present  obturator  in  position. 


tense  cicatricial  rigidity  in  the  resultant  palate,  which  consequently  is  lacking 
in  every  requirement  of  functional  activity  demanded  by  this  indispensable  organ 
of  speech. 

When  one  becomes  thoroughly  acquainted  with  the  physical  character  and 
functions  of  the  normal  velum  which  enables  it  to  make  the  almost  lightning-like 
movements  demanded  in  the  rapid  utterance  of  the  oral  elements  of  words,  and 
then  compare  this  to  the  rigid  cicatricial  structure  of  the  surgically  formed  velum 
with  no  possibility  of  anything  like  functional  movement,  or  even  possible  closure 
of  the  passage  of  air  and  voice  soiaids  to  the  nose  beyond  its  tensely  drawn  posterior 
border,  one  then  can  realize  how  fvitile  are  these  efforts  toward  a  surgical  production 
of  this  organ  of  speech. 

In  view  of  the  voluminous  amount  of  evidence  which  proves  that  the  surgical 
operation  when  performed  after  infancy  rarely  enables  patients  to  speak  without 
the  characteristic  cleft  palate  imperfections — to  say  nothing  of  the  thousands  of 
utter  failures  to  even  unite  the  borders  of  the  cleft— and  in  view  also  of  the  many 


412  PART  IX.     THE   PROSTHETIC  CORRECTION   OE  CLEET  PALATE 

evidences  which  have  been  exhibited  at  chnies  and  before  important  societies  and 
extensively  published,  which  prove  that  the  modern  vekmi  obturator  when  prop- 
erly constructed  and  followed  with  proper  training  enables  cleft  palate  patients 
to  speak  with  absolute  perfection  in  tone  and  articulation,  it  would  seem  that  the 
common  instincts  of  humanity  would  lead  all  honest  surgeons  to  hesitate  before 
taking  the  chance  of  wrecking  the  lives  of  so  many  patients  by  an  operation  which 
at  best  is  purely  experimental,  with  results  which  so  frequently  deprive  them  of  all 
future  possibilities  of  perfect  speech. 

It  was  the  natural  and  effective  action  of  the  Velum-Ubturator  which  led 
the  late  Dr.  John  B.  Murphy,  whose  name  is  known  throughout  the  world,  to 
write  one  of  his  characteristic  generous  letters  to  the  author  in  regard  to  a  cleft 
palate  patient  who  came  under  his  observation  after  wearing  the  obturator  a 
little  more  than  a  year.    He  says  in  part : 

' '  I  am  more  than  happy  to  say  that  I  was  pleased  and  surprised  to  observe 
that  such  perfect  correction  of  speech  could  be  accomplished  for  a  cleft  palate 
with  an  obturator.  I  feel  that  the  result  obtained  by  the  obturator  cannot  be 
excelled,  even  if  equalled,  by  the  most  successful  operation.  Your  patient  not 
only  spoke  well  with  perfect  enunciation  and  tone,  but  seemed  to  be  unconscious  of 
the  palate  in  her  mouth  in  any  position  of  the  head.  And  though  not  attached  to  a 
dental  plate  which  I  had  supposed  was  always  necessary,  it  seemed  to  rest 
securely  in  pos'tion,  responding  in  every  detail  to  movements  of  the  muscles  of 
speech,'  deglutition  and  inhalation,  just  as  though  it  were  the  natural  palate 
and  velum.  Its  motion  really  seems  uncanny , it  is  so  natural.  It  is  really  sad  that  so 
many  patients  are  permitted  to  go  through  life  with  defective  palates,  when  this 
simple  and  effective  method  of  yours  is  so  easily  applied.  One  really  has  to  see 
the  result  to  appreciate  the  great  benefit  that  is  derived  from  it." 

Importance  of  Proper  Instruction 

Those  who  perform  cleft  palate  operations — surgical  or  prosthetic — should 
fully  understand  the  imperative  mechanical  requirements  of  perfect  speech, 
and  should  also  be  able  to  give  to  their  patients  after  operations  at  least  proper 
foundation  instruction,  with  appropriate  notes  and  illustrative  matter  for  practice 
exercises  and  for  future  systematic  training.  Nor  should  the  responsibility  of  the 
operator  stop  here:  He  should  require  his  patients  to  return  to  him  after  a  few 
months  that  he  may  correct  errors  they  have  failed  to  suppress,  etc.  If  patients 
are  left  to  parents  or  friends  for  occasional  correction,  with  no  intelligent  or  guiding 
rules  for  instruction  or  continued  admonition  along  the  line  of  correct  practice, 
they  may  never  learn  to  speak  with  perfect  enunciation  and  tone  even  when  they 
are  supplied  with  the  most  perfect  surgical  or  artificial  palate,  because  of  the 
difUculty  of  overcoming  long  continued  habits  of  false  muscular  movements  which 
may  have  been  acquired  through  years  of  frantic  efforts  to  be  understood.  More- 
over, parents  and  members  of  the  family  cannot  as  a  rule  be  relied  upon  to  give 
adequate  instruction,  because  they  have  learned  to  understand  everything  the 


CHAPTER  I.     GENERAL  PRINCIPLES  413 

cleft  palate  member  says,  however  imperfectly  articulated,  and  therefore  will 
not  stop  him  as  they  should,  at  the  very  first  oral  element  of  speech  which  he  fails 
to  utter  perfectly.  Even  the  best  teachers  of  elocvition  rarely  employ  the  methods 
which  are  of  the  greatest  importance  in  the  teaching  of  cleft  palate  pupils. 

Therefore,  the  surgical  or  prosthetic  operation  should  be  regarded  as  the 
preliminary  work  in  giving  to  the  patient  the  proper  foundation  to  become  a  com- 
petent pupil  in  the  acquirement  of  perfect  speech.  The  success  in  the  training 
branch  of  the  operation  will  depend,  first,  upon  the  character  and  effectiveness  of 
the  operation,  and  second,  upon  the  ability  and  persevering  determination  of  the 
pupil.  If  the  restoration  is  one  which  does  not  promise  to  give  him  full  control 
of  the  speaking  functions  of  the  breath  blasts,  or  on  the  other  hand,  if  he  does  not 
appreciate  the  importance  of  perfect  speech,   the  results  are  very   likely  to  be 

unsatisfactory. 

Practical  Teaching 

The  teaching  of  cleft  palate  patients  to  speak  perfectly  commences  in  the 
author's  practice,  usually  at  the  first  or  second  sitting,  because  it  takes  about 
two  weeks,  in  connection  with  other  duties  of  practice,  to  make  and  fit  the  velum- 
obturator.  This  time  may  be  very  advantageously  employed  by  the  patient  in 
practicing  "tongue  and  lip  gymnastics"  or  the  voluntary  placing  of  the  tongue  and 
lips  in  every  possible  position,  which  will  often  be  of  great  help  later  when  he  is 
supplied  with  means  for  fully  directing  and  controlling  the  breath  blasts.  More- 
over, as  cleft  palate  patients  are  often  from  distant  localities,  and  though  required 
to  remain  at  least  two  weeks  after  the  completion  of  the  obturator,  the  time  is 
barely  sufficient  to  start  them  properly  in  the  course  of  training,  which  really 
should  be  continued  afterward  under  efficient  tutelage. 

At  the  first  sitting  the  case  is  diagnosed  with  a  view  to  determine  the  character 
of  the  cleft,  and  particularly  the  form  of  the  nasal  floor  and  adjoining  sinuses  to 
decide  the  method  that  should  be  employed  in  taking  the  impression.  At  this 
sitting  or  the  next,  a  thorough  diagnosis  of  the  speaking  qualifications  is  made  by 
having  the  patient  pronounce  as  distinctly  as  possible  short  words  containing  col- 
lectively all  the  consonant  oral  elements  of  speech  according  to  the  illustrated 
chart.  Reference  notes  of  the  pupil's  failures,  with  directions  for  correction,  should 
be  marked  under  each  of  the  oral  elements  on  the  chart,  to  be  later  given  to  the 
pupil  for  reference  in  the  absence  of  the  teacher ;  or  the  chart  may  be  supplemented 
with  notes  and  small  pencil  drawings  showing  the  relative  positions  of  the  oral 
organs  of  speech  illustrated  by  the  chart  and  verified  by  the  teacher. 

The  vowel  oral  elements  will  be  found  to  be  quite  perfectly  articulated  by  all 
cleft  palate  patients,  though  lacking  in  proper  resonance  and  tone  quality,  which 
will  come  through  special  training  after  the  muscles  have  learned  to  completely 
close  the  oro-nasal  passage  with  the  aid  of  the  obturator. 

In  these  first  lessons,  the  operator  will  be  able  to  determine  whicli  of  the  con- 
sonant oral  elements  are  imperfectly  made,  and  those  which  will  require  the  most 


414  PART   fX.     THE  PROSTHETIC  CORRECTION  OF  CLEFT  PALATE 

practice.  At  this  time,  tlie  patient  should  be  shown  the  positions  of  the  tongue  in  the 
enunciation  of  one  or  two  of  the  simple  sounds  which  require  the  least  amount  of 
air  pressure,  with  instruction  to  practice  these  elementary  sounds  alone  until  quite 
perfect  before  attempting  to  join  them  to  the  vowels  or  short  syllables.  This  later 
may  require  patiently  repeated  showings  with  every  aid  that  will  enable  the  pupil 
to  place  the  tongue  properly,  whose  control  and  direction  will  likely  be  as  awkward 
and  difificult  as  a  child  learning  to  walk,  as  he  has  never  before  had  these  same  mus- 
cles directed  by  the  nerves  into  the  speaking  movements  or  positions.  The  most 
arduous  but  necessary  part  of  the  teacher's  work  is  the  repetition,  over  and  over 
again,  of  the  required  sounds,  not  only  to  show  the  requisite  position  and  action 
of  the  oral  organs,  but  to  instill  into  the  mind  of  the  pupil  a  true  conception  of  the 
required  sounds,  and  the  fixation  of  the  sound-images. 

Sound-Images 

The  "sound-image"  of  an  oral  element  of  speech  is  the  individual  cognition  of 
the  exact  sound  of  that  element,  so  that  one  is  able  to  detect  the  slightest  imper- 
fection in  or  variation  from  it  when  it  is  made  by  others  or  himself,  in  the  same 
way  that  a  teacher  of  singing  is  able  to  detect  the  slightest  flat  or  sharp  of  a  musical 
note.  All  cleft  palate  patients,  who  have  been  obliged  to  speak  perhaps  for  years 
in  their  imperfect  way,  have  acquired  false  sound-images  of  all  the  utterances  which 
have  been  impossible  for  them  to  articulate  perfectly — with  the  result  that  they  are 
absolutely  unconscious  of  their  own  imperfections  and  wonder  why  they  are 
not  understood,  often  becoming  quite  indignant  when  people  who  are  not  accus- 
tomed to  hearing  them  speak  do  not  understand  them.  This  is  true  also  of  some 
singers  who  will  persist  in  flatting  or  sharping  certain  notes  because  they  have  ac- 
quired false  sound-images  of  those  notes. 

Albert  Salisbury  in  his  work  on  "Phonology  and  Orthoepy"  makes  the  following 
statement:  "The  exact  quaHty  and  character  of  each  oral  element  is  determined 
by  the  requisite  position  and  relation  of  the  several  organs  of  speech.  Correct 
enunciation  depends  primarily  on  correct  position  of  these  organs;  it  is  therefore 
of  vital  importance  that  the  teacher  should,  in  the  first  place,  know  what  the  correct 
sounds  are,  to  the  ear,  and,  in  the  second  place,  what  the  correct  positions  are, 
in  the  motith,  for  producing  the  exact  sound  required.  When  the  teacher  finds  in 
the  pupil  a  wrong  habit  of  sound-production,  the  first  point  of  attack  should  be  the 
securing  of  a  correct  sound-image;  the  next  should  be  the  securing  of  the  proper 
position  of  the  organs  for  producing  that  sound." 

This  applies  to  pupils  whose  organs  are  physically  normal,  or  at  least  capable 
of  development  to  normal  activities.  With  cleft  palate  pupils,  after  competent 
operations,  it  is  usually  necessary  to  reverse  this  order  and  teach  them,  first,  the 
positions  of  the  tongue,  etc.,  which  enable  them  to  make  the  proper  sounds. 

One  of  the  greatest  difficulties  encountered  by  teachers  in  the  correction  of 
defective  speech,  and  particularly  with  cleft  palate  pupils,  is  the  fixed  acquire- 


CHAPTER  I.    GENER.iL  PRINCIPLES  415 

ment  of  false  sound-images  of  certain  oral  elements  when  uttered  by  the  pupils 
themselves,  though  they  may  have  the  keenest  sense  of  the  proper  sounds  of  these 
elements  when  made  by  others.  One  of  the  most  effective  methods  of  instilling 
the  cognition  of  the  coiTect  sound  which  they  fail  to  recognize  when  uttered  by 
themselves,  is  for  the  teacher  to  repeat  distinctly  the  sound  over  and  over  again 
while  very  close  to  the  pupil,  and  accompanied  in  each  utterance  by  the  pupil  in 
an  effort  to  make  the  same  sound.  By  dropping  the  utterance  occasionally,  leaving 
the  pupil  to  make  it  alone,  the  progress  may  be  noted;  but  most  important,  the 
pupil  will  be  led  to  recognize  the  difference  between  the  false  sound  he  makes  and 
the  true  one,  which  will  stimulate  an  involuntary  effort  toward  a  closer  imitation. 
In  other  words,  when  the  sound-images  become  fixed  in  the  mind  of  the  pupil  as 
regards  his  own  utterances,  he  is  not  satisfied  until  they  are  correctly  articulated. 

When  a  word  or  syllable  is  found  to  be  imperfectly  articulated,  it  should  be 
at  once  divided  into  its  oral  elements  and  the  pupil  required  to  practice  upon  the 
isolated  elementary  sounds  in  which  he  fails,  until  he  becomes  proficient  in  that 
part,  before  he  attempts  to  pronounce  the  whole  word. 

It  can  be  seen  by  this,  that  the  psychologic  development  of  the  mental  concepts 
of  correct  articulate  sounds  of  the  oral  elements  of  spoken  words  is  quite  as  impor- 
tant as  the  restorative  operation  and  the  physical  development  of  the  inhibited 
activities  of  the  muscles.  Nor  will  true  development  in  either  case  arise  vuitil 
the  cleft  palate  patient  is  first  supplied  with  adequate  physical  means  that  will 
ultimately  enable   an   exact   duplication   of  the   indispensable   fvinctions   of  the 

velum-palati. 

Practical  Application  of  Methods  of  Instruction 

When  the  obturator  is  finished  and  the  patient  becomes  an  accredited  pupil  in 
phonology  and  orthoepy,  the  real  instruction  commences  toward  giving  him 
the  proper  foundation  for  speaking — not  only  in  perfect  articulation,  but  in  normal 
voice  tone  and  resonance. 

It  is  the  custom  of  the  author  to  give  lessons  to  the  pupil  in  a  closed  room 
free  from  the  embarrassment  of  listeners,  and  to  pursue  the  teaching  for  fifteen  or 
twenty  minutes,  and  then  leave  him  alone  for  an  hour's  practice.  As  a  supplement 
and  variation  from  the  breath  sounds  of  the  consonant  oral  elements,  the  pupil 
should  practice  on  the  phonetic  sounds  of  the  vowels — especially  that  of  a,  as 
a  in  ale,  a  in  at,  a  in  all  and  a  in  ah,  made  with  a  strong  forcible  gutteral  expression 
not  once  or  twice,  but  at  least  fifty  times,  one  after  the  other.  This  may  then  be 
joined  to  the  acquired  sounds  of  all  the  explosives  and  continued  with  the  same 
forcible  utterance.  The  object  of  this  exercise  is  to  strengthen  and  develop  the 
pharyngeal  and  palatal  muscles  so  that  they  will  firmly  and  involuntarily  close 
around  the  artificial  velum  completely  preventing  the  vocalized  air  from  escaping 
into  the  nose.  Tongue  gymnastics  are  of  the  greatest  importance  in  revivifying  the 
inhibited  activities  of  the  tongue  by  voluntary  movements  in  direction,  position, 
and  rapidity.    Along  this  line  the  rapid  utterance  of  all  the  explosive  oral  elements 


41()  PART   IX.     THE  PROSTHETIC  CORRECT/OX   OF  CLEFT   PALATE 

joined  to  each  one  of  the  vowels,  as  ba,  be,  bf,  bo,  bu,  taking  up  each  one  of  the 
explosives  shown  by  the  chart  in  succession,  commencing  with  the  labials  ba  and 
pa,  followed  with  the  labio-dentals  fa,  the  linguo-dentals  tha,  and  the  Unguals 
da,  ta,  cha,  ka,  ga.  When  all  these  are  distinctly  uttered,  follow  this  practice  by 
joining  the  explosives  to  all  the  phonetic  sounds  of  the  vowels.  Again,  the  rapid 
utterance  of  single  elementary  sounds  in  musical  rliythm  as,  la — lalala — la, — la, 
etc.,  will  be  found  very  difficult  for  most  cleft  palate  pupils  to  utter  rapidly  at  the 
start. 

The  pupil  may  quietly  practice  all  the  voiceless  Ijreath  sounds  of  the  consonants 
when  not  otherwise  engaged.  Even  the  sibilants  of  c  and  s  may  be  practiced 
quietly  at  almost  all  times,  at  home  or  on  the  street,  when  there  are  no  interferences. 

The  patient  should  be  kept  in  training  under  immediate  supervision  and 
instruction  until  there  is  every  reason  to  believe  he  will  follow  up  the  instruction, 
aided  by  the  drawings,  or  that  he  will  be  placed  in  the  hands  of  competent  teachers. 

With  patients  too  young  to  understand  and  appreciate  the  requirements  and 
the  necessity  of  continued  practice  ixntil  they  have  fully  acquired  the  correct 
utterances  and  "sound-images"  of  the  oral  elements  they  fail  to  articulate,  the 
instruction  sheets  should  be  given  to  the  parents  for  their  own  instruction  as 
teachers,  or  for  the  information  of  teachers  who  are  employed  for  this  purpose. 

If  a  surgical  operation  has  been  performed  during  infancy,  or  before  the  child 
has  commenced  to  talk  (and  this  in  the  opinion  of  the  author  is  the  only  time 
when  a  surgical  operation  for  cleft  palate  should  ever  be  performed),  the  rule  in 
regard  to  the  instruction  sheets  should  be  considered  quite  as  imperative,  and  should 
include  all  the  consonant  oral  elements  of  speech  which  cleft  palate  patients  in 
general  fail  to  articulate  distinctly.  Instruction  should  then  begin  at  the  very  first 
tvord  the  child  attempts  to  articulate.  In  that  way  he  will  very  soon  acquire  the 
sound-image,  and  his  efforts  to  reach  it  will  act  as  a  mechanical  stiiimlalioii  toward 
natural  growth  development  of  the  velum  and  co-operating  muscles.  It  is  the 
lack  of  velum  tissue  growth  in  proper  proportion  to  the  growth  and  development 
of  surrounding  parts,  due  to  the  disuse  of  the  speaking  muscles,  which  causes  most 
of  the  failures  that  result  from  infantile  surgical  operations.  If  the  cleft  is  closed 
skillfully  at  that  time,  and  the  surgically  corrected  velum  is  sufficiently  adequate 
to  close  the  oro-nasal  passage  when  the  child  conniioices  to  speak,  and  if  from  that 
time  on  there  is  intelligent  insistence  that  he  shall  speak  distinctly,  the  results 
without  doubt  would  be  all  that  could  be  desired. 

Importance  of  Systematic  Instruction  in  the  Management 
OF  the  Lips,  Tongue,  Voice,  Etc 

The  operator  or  teacher  will  frequently  be  surprised  to  find  how  much  im- 
provement can  be  made  by  proper  instruction  in  the  speech  of  nearly  all  patients, 
even  before  they  are  supplied  with  any  other  aid.  This  is  easily  accounted  for  by 
the  fact  that  they  rarely  have  received  from  their  parents  or  school  teachers  the 


CHAPTER  I.    GENERAL  PRINCIPLES  417 

slightest  systematic  instruction  in  regard  to  the  management  of  the  hps,  tongue,  or 
voice,  because  it  is  an  exceedingly  seiisitive  subject  at  home  and  abroad,  evoking 
only  pity  for  this  terrible  deformity,  of  which  the  immediate  friends  are  inclined  to 
believe  that  nothing  except  an  operation  will  enable  theni  to  speak  more  perfectly. 
Besides  this,  the  fact  that  the  family  soon  learn  to  fully  understand  everything  the 
patient  says,  causes  him  to  believe  that  he  speaks  quite  perfectly.  For  instance, 
nearly  all  cleft  palate  patients  before  receiving  aid  will  make  fairly  close  imitations 
with  the  throat  muscles,  of  the  sibilant  and  many  other  aspirate  and  explosive 
sounds  to  whose  defects  they  are  wholly  blind,  though  quite  noticeable  and  to 
strangers  not  always  intelligible.  As  the  sibilant  is  such  an  important  element  of 
correct  speech  when  made  properly  at  the  tip  end  of  the  tongue  with  a  high  thin 
whistle,  and  as  it  requires  but  a  slight  pressure  of  air,  it  is  usually  their  first  lesson. 
Occasionally  they  succeed  in  distinctly  sounding  s  in  yes,  even  before  the  artificial 
palate  is  inserted,  though  never  having  properly  made  it  before. 

Again,  one  will  meet  patients  with  large  open  clefts  who  will  distinctly  pronounce 
words  containing  certain  oral  elements  which  the  majority  of  patients  cannot 
intelligibly  approach  before  the  operation.  And  perhaps  this  same  patient  may  have 
the  greatest  difficult}'  in  accjuiring  the  perfect  enunciation  of  other  articulate  sounds 
that  are  usually  quite  easy  to  accjuire.  One  patient  twenty-five  years  of  age  rapidly 
learned  to  speak  with  remarkable  distinctness  except  in  joining  the  elements  of 
t  and  o  in  toe,  which  took  months  of  persevering  practice  to  acquire.  Another 
patient,  about  sixteen  years  of  age,  who  otherwise  spoke  perfectly,  was  unable  for 
months  to  unite  the  sound  of  b  with  ga,  in  the  word  began. 

One  of  the  patients  who  was  exhibited  by  the  author  at  a  clinic  of  the  National 
Dental  Association  in  1918,  distinctly  articulated — and  mostly  with  strong  oral 
resonance — even  the  most  tongue-twisting  words  that  were  given  to  her  by  the 
members,  except  the  plural  of  words  ending  in  g.  In  pronouncing  dogs,  she  gave 
the  clear  sibilant  as  in  cats,  instead  of  the  vocalized  sibilant  z.  As  this  patient 
had  been  wearing  the  obturator  only  a  short  time,  it  is  needless  to  say  that  this 
important  element  of  speech  was  soon  acquired. 

Another  patient  eleven  years  of  age  was  also  presented,  for  whom  the  con- 
struction of  the  obturator  had  just  been  started.  The  impression  and  the  method 
of  taking  it  was  described;  also  there  was  shown  in  the  mouth  the  modeling- 
compound  trial  model  of  the  obturator,  which  though  much  heavier  than  the  final 
hard-rubber  one,  perfectly  retained  its  position  without  being  sustained  artificially. 
This  exhibition  was  quite  an  advantage,  because  it  enabled  the  author  to  show 
clearly  the  action  of  the  pharyngeal  muscles  in  relation  to  the  veil  of  the  obturator 
in  the  act  of  closing  the  passage  to  the  nose.  This  little  patient  had  been  operated 
upon  seven  times  surgically  for  the  closure  of  the  cleft,  with  the  result  that  all  the 
soft  palatal  tissue  and  a  portion  of  the  pharyngeal  tissue  were  destroyed.  The 
object  in  mentioning  this  case  here  is  to  say  that  even  before  the  insertion  of  the 
obturator,  and  notwithstanding  the  loss  of  so  much  tissue,  she  could  distinctly 


418  PART   IX.     THE   PROSTIIEriC  CORRECTION   OF  CLEET   PA  [.ATE 

enunciate — after  a  very  little  preliminary  training— -a  large  number  of  the  explosive 
and  aspirate  oral  elements  of  speech,  and  seemingly  with  a  normal  action  of  the 
tongue  and  lips,  although  not  sharply  or  fully  without  the  nasal  tone.  This  in 
itself  is  very  unusual  before  receiving  thorough  instruction. 

To  continue  the  history  of  this  interesting  case:  One  week  after  the  finished 
obturator  was  placed  in  the  mouth,  many  of  the  most  prominent  surgeons  and 
dentists  of  Chicago  came  by  invitation,  to  see  the  obturator  in  action,  and  all  were 
surprised  by  her  very  rapid  acquirements  in  so  short  a  time. 

One  of  the  most  important  peculiarities  of  the  present  velum  obturator,  and 
the  one  which  places  it  on  a  scientific  basis  in  its  relation  to  all  the  requirements 
of  articulation  and  resonance,  is  the  feature  that — in  its  typical  state — it  does 
not  require  any  uttaclnnent  to  a  plate  or  other  dental  device  to  hold  it  in  position; 
it  being  sustained  through  its  perfectly  fitted  nasal  and  palatal  extensions,  and 
mostly  because  of  the  peculiar  form  and  position  of  the  veil  and  its  relation  to  the 
walls  of  the  pharynx  and  the  action  of  the  pharyngeal  and  palatal  muscles. 

The  importance  of  doing  without  a  supporting  plate  for  the  obturator  is  not 
merely  one  of  convenience  to  the  patient,  but  it  is  the  one  principle  which  permits 
all  the  requirements  of  normal  speech. 

The  most  potent  factors  of  the  remarkable  success  of  this  form  of  obturator 
in  the  restoration  of  speech  are  its  extremely  light  weight  and  its  free  mobility  and 
quick  response  to  the  slightest  movement  of  the  muscles;  and  when  it  is  sur- 
rounded and  within  their  grasp  in  its  act  of  completely  closing  the  passage  to  the 
nose,  it  takes  the  same  favorable  position  in  relation  to  the  vibratory  voice  blasts 
as  the  normal  velum-palati,  whose  function  and  activities  it  seems  to  imitate  closely, 
and  as  Dr.  Murphy  said:  "Its  motion  really  seems  uncanny,  it  is  so  natural." 
This  will  be  appreciated  when  we  come  to  study  all  the  requirements  in  the  mecha- 
nism of  speech. 

In  works  upon  general  phonology  and  orthoepy,  it  has  not  been  regarded  as 
especially  important  to  understand  the  anatomy  and  physiology  of  the  palatal  and 
pharyngeal  muscles,  or  the  exact  details,  with  illustrations,  of  the  relative  positions 
and  action  of  the  tongue  and  other  oral  organs  of  speech ;  nor  is  there  any  particular 
stress  laid  upon  the  importance  of  a  complete  closure  of  the  oro-nasal  passage, 
because  general  instruction  in  the  art  of  speaking  perfectly  pertains  to  that  class 
of  pupils  whose  muscles  and  controlling  nerves  are  sufficiently  unimpaired  to  require 
no  more  than  the  developing  stimulation  of  right  teaching  and  practice  toward  the 
psychologic  acquirement  and  attainment  of  the  exact  sounds  of  the  oral  elements 
not  properly  articulated. 

In  the  training  toward  this  object,  the  specialized  organs  of  speech  intuitively 
take  the  right  positions  without  being  told,  so  to  speak,  whereas,  the  require- 
ments of  teaching  are  quite  different  with  cleft  palate  pupils,  who  up  to  the  time 
of  the  operation  have  l^een  debarred  the  power  to  control  the  force  and  direction 
of  the  speaking  breath  blasts  for  the  utterance  of  nearly  all  the  consonant  oral 


CHAPTER  I.    GENERAL  PRINCIPLES  419 

elements,  and  who  therefore  have  been  driven,  in  their  efforts  to  be  understood, 
to  a  wrong  and  inadequate  employment  of  those  muscles  which  were  not  intended 
for  speech,  and  a  complete  disuse  of  the  muscles  which  should  control  the  main 
organs  of  normal  speech,  with  the  result  that  the  function  and  action  of  the  prin- 
cipal speaking  muscles  and  guiding  nerves  are  wholly  untrained,  and  in  addition 
to  this  the  palatal  and  pharyngeal  muscles  are  more  or  less  atrophied.  Conse- 
sequently,  the  functional  position  and  action  of  the  vokmtary  oral  organs  of  speech 
must  be  carefully  and  specifically  taught  before  they  can  be  expected  to  make  the 
proper  utterances. 

Moreover,  one  of  the  greatest  difficulties  to  overcome  arises  from  the  fact 
that  the  muscles  have  acquired  false  habits  of  action  in  their  efforts  to  produce 
intelligible  speech,  which  is  mainly  due  to  the  acquirement  of  false  conceptions  of 
the  articulate  sounds  the  piipil  utters.  But  when  the  proper  sound-image  is 
stamped  indelibly  upon  his  mind,  it  will  then  be  surely  followed  by  the  involuntary 
movement  of  the  right  muscles  for  its  production,  providing  the  physical  machinery 
is  sufficiently  adequate.  In  the  same  manner  that  the  pupil  at  the  piano  must 
at  first  be  taught  how  and  where  to  place  the  fingers  on  the  keys  to  get  the 
required  sounds,  while  later  this  is  followed  with  hardly  a  thought  of  the  fingers, 
which  are  now  almost  wholly  directed  by  the  efferent  motor  impulses  from  ganglia 
imder  the  subconscious  control  of  the  brain,  that  is  thinking  only  of  the  musical 
staff  or  the  tone-images  which  it  indicates. 

The  training  of  cleft  palate  pupils,  therefore,  should  be  that  which  will  most 
successfully  utilize  the  impaired  palatal  and  pharyngeal  muscles  with  the  view 
of  stimulating  their  development  toward  a  revivification  of  their  inhibited  activi- 
ties, for  no  really  successful  prosthetic  or  surgical  operation  can  be  accomplished 
without  their  functional  co-operation.  Furthermore,  in  order  that  patients  receive 
the  full  benefit  of  the  operation,  a  character  of  teaching  and  training  that  is  es- 
pecially adapted  to  this  class  of  pupils  is  of  the  utmost  importance.  The  respon- 
sibility of  this  must  lie  with  the  operator,  or  a  teacher  who  has  full  knowledge  of 
the  special  needs  and  methods  which  should  be  employed.  This  can  only  be  accom- 
plished, as  stated  before,  with  a  perfect  understanding  of  the  phonologic  mechanism 
of  normal  speech  and  those  principles  of  teaching  which  should  be  employed  with 
pupils  who  have  been  wholly  deprived  of  the  use  of  the  principal  organs  of  speech. 


CHAPTER  11 
PHYSIOI.OniC   AND   PHONETIC   PRINCIPLES    IN   THE   ART   OF    SPEAKING 

It  will  be  impossible  in  the  short  space  of  this  chapter  to  give  more  than  a  glance 
at  the  general  principles  of  phonology,  omitting  mtich  that  should  be  regarded  as 
of  great  importance,  foimd  in  works  upon  general  phonology  and  orthoepy,  to  which 
the  student  is  earnestly  referred. 

Those  principles,  however,  which  pertain  especially  to  this  particular  work  are 
given  here  in  the  fullest  detail,  arranged  by  the  author  for  the  teaching  of  cleft 
palate  pupils  to  speak;  and  designed  especially  to  emphasize  the  importance 
of  methods  whose  employment — though  not  so  material  in  the  general  teaching  of 
phonology — is  of  the  greatest  importance  in  this  department  of  dentistry.  There- 
fore, much  stress  has  been  laid  upon  the  fttnctions  of  the  palate — particularly  the 
velum-palati — and  to  the  peculiar  defects  in  the  mechanism  which  arise  from  its 
impairment.  In  order  to  anive  at  the  most  successful  correction  of  those  special 
imperfections,  the  author  has  found  it  necessary  to  divide  or  classify  the  consonant 
oral  elements  upon  a  basis  which  it  is  hoped  will  more  sharply  illustrate  slight 
but  important  differences  in  enunciation  which  might  otherwise  be  easily  over- 
looked. 

As  all  the  vowel  elements  are  distinctly  enunciated  by  persons  with  open 
cleft  palates — though  ivith  imperfect  tone — the  need  of  teaching  the  required  posi- 
tion of  the  tongue,  etc.,  in  these  utterances,  may  be  considered,  in  this  work  for 
the  instruction  of  cleft  palate  patients,  of  lesser  importance.  Consequently, 
there  has  been  given  to  the  vowel  branch  no  more  than  a  cursory  explanation,  with 
no  illustrations;  the  principal  teaching  being  devoted  to  the  more  exhaustive  and 
systematic  explanation  and  illustration  of  the  consonant  utterances  which  cleft 
palate  patients  have  been  unable  to  enunciate  properly. 

It  would  be  well  to  state,  however,  in  this  connection,  that  the  vowel  or  vocal 
utterances  are  the  most  important  elements  of  speech,  as  they  are  the  only  ele- 
ments which  are  purely  composed  of  the  vibratory  voice  blasts;  consequently,  they 
are  the  only  parts  of  speech  which  present  the  vocally  vibratory  audible  sounds, 
except  when  certain  consonant  utterances  are  intoned  at  the  vocal  cords,  as  in 
pronouncing  z,  whereas,  the  true  voiceless  consonant  sounds  are  made  by  a  forcible 
expelling  of  the  un vocalized  air  through  constricted  openings  and  regulated  passages 
in  their  function  of  giving  the  beginning  and  finishing  touches  to  the  vocals.  Not- 
withstanding the  fact  that  nearly  all  vowel  utterances  with  open  cleft  palates 
are  distinctly  articulated,  they  are  completely  lacking  in  the  important  elements  of 
tone  and  resonance,  because  the  vocalized  air  passes  freely  into  the  nasal  chambers, 

420 


CHAPTER  II.    PHYSIOLOGIC  AND  PHONETIC  PRINCIPLES  421 

imparting  to  the  sound  the  nasal  quahty.  One  can  sec  by  this  how  a  complete 
closure  of  every  passage  to  the  nasal  chambers  is  necessary  for  the  perfect  utter- 
ance of  the  vowels  as  well  as  of  the  consonant  oral  elements. 

The  Physiologic  Mechanism  of  Speech 

The  framework  of  the  speaking  machine  is  the  thorax,  the  trachea,  the  pharynx, 
the  oral  and  nasal  cavities,  the  jaws,  the  dentures,  and  the  roof  of  the  mouth.  The 
active  or  mobile  parts  of  this  machine  are  the  diaphragm,  intercostal  muscles, 
vocal  cords,  pharyngeal,  palatal,  lingual,  labial,  and  buccinator  muscles.  To  these 
may  be  added  the  hyoid  and  masseter  muscles,  which  aid  in  regulating  the  different 
required  sizes  of  the  oral  cavity  by  opening  and  closing  the  jaws.  The  action  of  this 
co-ordinated  machinery,  which  is  fed  with  expirations  of  air  from  the  lungs,  and 
whose  product  is  spoken  language,  is  worthy  of  the  deepest  study  by  dentists  and 
oral  surgeons,  whose  every  department  of  applied  science  is  concerned  in  perfecting 
or  in  marring  its  mechanism. 

The  sensations  which  we  cognize  as  sounds  of  every  character,  reach  the  brain 
through  the  auditory  apparatus,  which  is  thrown  into  functional  activity  usually 
by  vibratory  wave  movements  of  air  striking  the  drum  or  diaphragm  of  the  ear. 
A  somewhat  prolonged  and  forcible  expiration  of  breath  from  the  lungs  throws  into 
vibrations  the  vocal  cords  of  the  larynx,  which  in  turn  impart  their  vibrations  to 
the  air,  and  give  rise  to  the  sound  we  call  voice.  Its  quality,  pitch,  and  loudness 
are  regulated  by  the  character  of  the  tissues  which  compose  the  cords,  their  tension, 
and  the  force  of  the  air  blasts. 

As  these  speaking  air  blasts  are  forced  upward  through  the  trachea,  the  vol- 
ume of  air  upon  leaving  the  glottis  is  divided  by  the  action  and  inaction  of 
the  vocal  cords  into  a  rapid  succession  of  vibrating  and  unvibrating  zones.  The 
vibrating  portions  are  the  voice  sounds,  which  are  employed  in  enunciating 
the  vowel  oral  elements  of  speech,  and  in  giving  to  them  their  peculiar  individ- 
ual timbre  and  normal  voice  tone  quality  and  resonance.  The  voiceless  or 
unvibratory  air  blasts,  when  forced  into  the  oral  cavity,  are  converted  into 
the  explosives  and  fricative  sounds  which  compose  the  oral  elements  of  the  con- 
sonants. 

As  the  column  of  speaking  breath  travels  through  the  movith,  it  comes  under 
the  influence  of  certain  definite  muscular  movements  and  restrictions,  which  stop 
or  interrupt  its  free  passage  or  force  it  into  certain  chambers  or  channels  of  different 
forms  by  which  it  is  molded  into  speech  or  vocal  language.  Therefore,  to  speak 
distinctly,  there  are  certain  physical  requirements  which  must  be  fulfilled.  Among 
the  foremost  of  these  is  the  necessity  of  completely  closing  the  oro-nasal  passage 
so  that  in  all  parts  of  speech,  except  the  sounds  of  m,  n,  and  ng,  not  a  particle  of 
the  expired  breath  used  in  talking  can  escape  into  the  nose;  otherwise,  as  will  be 
shown,  it  is  impossible  to  enunciate  properly  and  distinctly  all  vowel  and  nearly 
all  consonant  utterances,  except  in  phenomenal  cases. 


422  PART  IX.     THE  PROSTHETIC  CORRECTION   OF  CLETT  PALATE 

In  the  involuntary  intermitting  function  of  closing  and  opening  the  passage 
to  the  nose,  the  velum-palati  acts  with  almost  lightning-like  rapidity  in  the  perfect 
enunciation  of  rapidly  spoken  words,  and  especially  those  words  in  which  certain 
oral  elements  which  demand  that  this  passage  be  open,  are  joined  to,  or  lie  between, 
other  oral  elements  which  demand  that  it  be  closed.  For  instance,  in  the  word  and, 
the  beginning  vowel  a  requires  this  passage  closed  for  resonating  quality,  the  n 
requires  with  equal  importance  that  it  be  open  for  its  peculiar  nasal  tone  quality, 
and  the  d  that  it  be  again  fully  closed  for  its  distinct  explosive  articulation. 

One  can  understand  by  this  example  alone  something  of  the  difficulties  which 
confront  the  surgical  operator  in  an  endeavor  to  not  only  close  extensive  clefts 
of  the  hard  and  soft  palate  for  patients  older  than  five  years,  but  to  construct  a 
plastic  velum,  necessarily  composed  largely  of  cicatricial  tissue,  which  will  act  with 
that  light  sensitive  mobility  that  is  demanded  of  the  normal  palate  in  its  activi- 
ties of  perfect  speech ;  and  also  how  impossible  it  would  be  to  accomplish  these 
indispensable  requisites  of  speech  with  any  form  of  artificial  palate  or  obturator 
that  is  attached  to  a  dental  fixture,  or  one  that  will  not  quickly  and  rapidly  move, 
as  does  the  normal  velum,  with  the  very  lightest  touch  of  the  muscles  which 

control  it. 

The  Velum-Palati 

In  order  to  obtain  an  intelligent  comprehension  of  the  scientific  principles  and 
practical  activities  of  a  modern  obturator  in  the  coiTcction  of  speech,  it  may  be  well  to 
first  briefly  call  attention  to  the  indispensable  functions  of  the  velum-palati,  because  it 
is  solely  through  the  loss  or  impairment  of  this  important  organ  that  renders  perfect 
speech  impossible.  Therefore,  anjrthing  which  is  capable  of  restoring  the  possibilities 
of  perfect  speech  to  cleft  palate  patients— whether  by  surgical  or  prosthetic  methods- 
must  also  be  capable  of  imitating  the  action  and  function  of  the  normal  velum. 

The  first  and  most  indispensable  part  of  the  involuntary  function  of  the  normal 
velum  is  its  act  of  completely  closing  the  oro-nasal  passage,  in  order  that  the  air 
blasts  of  speech  may  be  wholly  directed  and  forcibly  thrown  into  and  through 
the  oral  cavity,  to  be  formed  into  the  articulate  sounds  of  speech.  This  is  absolutely 
necessary  for  the  perfect  enunciation  of  all  the  oral  elements  of  speech,  except 
those  of  m,  n,  and  ng,  which  will  be  explained  later. 

The  second  important  part  of  its  function  is  its  light  sensitive  rapidity  of  move- 
ment, which  will  be  appreciated  when  we  remember  that  the  oro-nasal  passage  must 
be  closed  and  opened  at  the  very  beginning  and  ending  of  nearly  every  oral  element 
in  a  large  proportion  of  spoken  words  which  we  distinctly  enunciate,  and  that  the 
words  of  the  English  language  contain  from  one  to  eight  oral  elements,  which  when 
spoken  rapidly,  require  an  almost  inconceivable  rapidity  of  muscular  movement. 

The  third  important  part  of  its  function  pertains  to  normal  voice  tone  quality 
and  resonance.  When  we  consider  that  the  main  resonating  chambers  of  our 
wonderful  speaking  instrument  lie  above  the  hard  and  soft  palate,  we  can  fully 
understand  how  necessary  it  is  that  the  voice  vibrations  must  be  freely  and  unin- 


CHAPTER  II.    PHYSIOLOGIC  AND  PHONETIC  PRINCIPLES  423 

terruptedly  imparted  to  these  chambers  in  order  to  produce  the  required  tone  and 
melody  of  perfect  speech. 

The  complete  closixre  of  the  oro-nasal  passage,  principally  by  the  velum- 
palati,  enables  the  performance  of  two  indispensable  functions  of  speech.  First,  it 
enables  the  forcing  of  the  unvocalized  air  into  and  through  the  speaking  tube  of  the 
mouth  with  that  forcible  pressure  which  is  necessary  for  the  distinct  and  perfect 
entmciation  of  the  consonant  explosive  and  aspirate  oral  elements,  and  which  would 
not  be  possible  with  this  passage  open,  any  more  than  it  would  be  possible  for  a 
syringe  or  a  chip-blower  to  functionate  with  a  hole  through  its  side.  Second,  in 
this  act  of  closure,  it  enables  the  production  of  natural  voice  tone  cjuality  and  mel- 
ody of  resonance,  in  both  speaking  and  singing,  which  also  would  not  be  possible 
with  this  passage  open.  It  wotildseem.  that  the  vibratory  voice  blasts  of  the  vocals, 
when  confined  to  the  oro-pharyngeal  speaking  tube,  are  thrown  into  more  intensi- 
fied vibrations,  whose  wave  impacts  are  thus  more  effectually  communicated  and 
transmitted  through  the  medium  of  the  velum-palati  and  surrounding  tissues  to  the 
resonating  chambers  of  the  head. 

The  student  will  appreciate  this  if  he  will  forcibly  utter  the  vowel  oral  element 
ah,  and  note  the  strong  natural  oral  tone  and  resonating  voice  quality,  which 
in  the  less  rapid  vibrations  of  low  tone  registers,  produces  a  perceptible  quivering 
of  the  throat  tissues,  easily  felt  by  the  fingers  on  the  outside  of  the  throat.  Now 
make  the  same  effort  with  the  palate  dropped  so  that  the  vibrating  air  can  pass 
freely  into  the  nose,  and  note  the  nasal  tone  and  lack  of  forceful  resonating  voice 
quality.  In  this  process,  the  thin  sensitive  velum-palati,  stretched  backward  in 
drum-like  tenseness  toward  the  walls  of  the  pharynx  to  co-operate  with  the  pharyn- 
geal muscles  in  closing  the  passage  to  the  upper  pharynx  and  nose,  is  an  admirable 
transmitter  of  the  voice  waves  to  the  real  sounding-board  of  the  head.  An  impor- 
tant feature  in  this  act  is  the  position  of  the  velum  lying  almost  at  right  angles  to  the 
voice  blasts  directly  from  the  glottis.  It  is  this  position  of  the  veil  of  the  obturator, 
also,  that  enables  it  to  so  closely  imitate  the  action  and  function  of  the  normal  velum. 

It  will  be  observed  that  the  attainment  of  natural  voice  quality,  with  its  res- 
onance and  melody  in  both  speaking  and  singing,  is  not  accomplished  by  allowing 
the  original  vibratory  air  of  the  voice  to  enter  the  nasal  chambers,  otherwise  there 
wotdd  result  an  unpleasant  nasal  tone,  devoid  of  true  resonating  richness.  The 
vocalized  air  is  therefore  completely  and  wholly  stopped  at  the  velum-palati, 
which  in  consequence  is  thrown  to  greater  vibratory  and  transmitting  activity, 
imparting  its  intensified  somid  waves  to  the  upper  resonating  chambers,  where  it  is 
properly  molded  and  sent  forth  to  the  outer  air  as  natural  speaking  and  singing 

voice  tones. 

Resonance 

The  quality  of  voice  known  as  resonance  and  melody,  which  is  quite  as  impor- 
tant to  perfect  speech  and  vocal  music  as  distinct  articulation,  no  doubt  starts 
to  be  imparted  to  the  voice  in  the  trachea  and  continues  to  characterize  its  tone  by 


424  /MA'7'   IX.     THE  PROSTHliTIC  CORRECT/OX   OE  CLEET   EM. ATE 

different  forms  of  the-  jjharyngeal  and  oral  channels  throngh  which  it  passes  in  the 
mechanism  of  speech. 

The  principal  ])ortion  of  normal  speech  resonance,  however,  is  imparted  to 
the  voice  in  the  nasal  chambers  where  resides  the  real  "sounding-board"  of  the 
speech  mechanism.  The  vibratory  air  itself,  from  the  vocal  cords,  does  not  enter 
these  chambers  except  when  uttering  the  nasals — m,  n,  and  ng — it  being  prevented 
principally  by  the  velum-palati  through  which  the  voice  vibrations  readily  pass. 
This  complete  closure  of  the  passage  to  the  nose  is  important  in  the  production 
of  normal  tone  resonance.  The  failure  to  close  this  passage  completely  in  the  utter- 
ance of  all  the  vocals,  characterizes  the  sounds  as  more  or  less  nasal,  and  to  that 
extent  destroys  the  true  resonating  and  resounding  quality  of  perfect  vocal  speech ; 
whereas,  its  complete  closure  intensifies  the  vibrations  of  air,  and  consequently 
the  sound  above  the  velum. 

A  person  outside  of  a  thin  hermetically  sealed  door  can  be  distinctly  under- 
stood by  one  on  the  inside  if  he  speaks  loudly  enough,  and  yet  not  a  particle  of 
the  vibratory  air  of  voice,  per  se,  penetrates  the  door.  The  substance  of  which 
the  door  is  coniposed  is  a  transmitter  of  the  voice  vibrations. 

It  will  be  seen,  therefore,  that  the  velum-palati  in  the  normal  state  is  not  only 
the  chief  organ  in  distinct  articulation  by  completely  closing  the  oro-nasal  passage, 
but  it  is  also  a  perfect  transmitter  of  voice  vibrations  which  gives  to  speech  its  main 
resonating  quality.  In  fact,  pure  resonance  and  clear  vocal  tone  quality  in  all 
vowel  utterances  of  the  English  language  seem  to  require  this  closure — a  thing 
which  cannot  be  said  of  the  French  and  possibly  many  other  languages.  In 
speaking  any  of  our  vowels  with  a  forcible  gutteral  prolongation,  we  notice  the 
distinctly  marked  difference  in  the  character  and  quality  of  the  tone  with  this 
passage  closed  and  with  it  open;  this  plainly  indicates  the  functional  mechanism 
by  which  the  voice  in  nearly  all  requirements  of  speech  readily  passes  through  a 
closed  palate  to  the  upper  resonating  chambers,  and  not  back  of  an  open  or  partially 
open  palate. 

It  is  only  through  an  understanding  of  the  functions  of  the  velum-palati  that 
we  gain  a  true  conception  of  its  indispensable  action  in  the  mechanism  of  speech  and 
are  able  to  realize  fully  the  object  and  difficulties  of  an  operation  for  the  restora- 
tion of  a  cleft  palate  by  surgical  or  artificial  means.  It  forms  also  an  important 
foundation  for  an  intelligent  comprehension  of  the  art  of  speaking  correctly. 

The  Oral  Elements  of  Vowels  and  Consonants 

The  alphabetical  symbols  wdiich  stand  for  the  oral  elements  of  speech  in  the 
English  language  are  divided  into  vowels  and  consonants.  An  oral  element,  or 
elementary  sound,  is  one  which  is  uttered  with  a  single  impulse,  always  with  the 
same  mechanism,  and  which  cannot  be  divided  into  separate  sounds.  Words  are 
composed  of  oral  elements  the  same  as  chemical  compounds  are  composed  of  chem- 
ical elements.     Like  chemical  elements  also,  they  are  represented  to  the  eye  by 


CHAPTER   11.     PHYSIOLOGIC  AND  PHONETIC  PRINCIPLES  425 

symbols  composed  of  one  or  more  letters  of  the  alphabet.  For  instance,  in  the  word 
cat,  there  are  three  oral  elements,  whose  phonism  may  be  represented  to  the  eye  as 
ka-a-tii,  whereas,  in  ought,  a  word  of  five  letters,  there  are  only  two  oral  elements, 
au-tu. 

In  practicing  separate  utterances  of  the  oral  elements  which  are  represented 
in  written  language  by  the  alphabet,  or  symbols  of  speech,  they  should  be  enunciated 
with  a  short  quick  utterance  so  as  to  avoid  mixing  the  voiceless  breath  consonant 
sounds  with  the  adjoining  voice  sounds  of  the  vowels.  In  representing  to  the  eye 
of  the  student  or  the  pupil  the  detached  phonetic  sounds  of  the  explosive  oral 
elements,  for  teaching  purposes  in  this  work,  the  symbol  u  or  a  (i.  e.,  short)  is 
added  to  the  consonant  letter.  Thus  in  representing  the  explosive  oral  element 
of  b  in  the  word  but,  it  is  bu,  uttered  with  a  quick  breath  emission  by  the  sudden 
parting  of  the  lips,  and  by  not  permitting  the  sound  to  run  into  the  vocal  sound 
of  the  vowel  u.  The  oral  element  of  u  in  but  is  sounded  like  uh,  and  the  t  is  repre- 
sented as  ta  or  tu,  and  is  made  with  a  sudden  explosive  breath  emission,  etc. 

While  it  is  a  fact  that  in  the  perfect  pronunciation  of  a  word  the  explosive 
elements  are  indistinguishably  joined  to  the  vowel  elements,  the  sounds  are  there 
nevertheless,  and  their  distinct  and  separate  utterance  should  be  considered  as  the 
first  requirement  in  teaching  cleft  palate  pupils  to  enunciate  any  of  the  words  in 
which  the  explosives  occur,  as  these  are  the  utterances  in  which  they  most  often 
fail,  because  of  the  impossibility  of  accumulating  a  sufficient  pressure  of  potential 
air  back  of  the  stop  before  it  is  suddenly  let  loose. 

When  a  syllable  or  a  word  is  pronounced  properly,  it  is  characterized  by  a 
succession  of  all  the  oral  elementary  sounds  of  which  it  is  composed.  Each 
one  of  these  soiDids  requires  a  different  niitscidar  movement,  and  however  quickly  the 
word  is  spoken,  if  uttered  distinctly,  all  the  movements  and  positions  necessary  for 
the  utterance  of  each  separate  elemoit  must  always  occur  in  the  succession  of  their 
position  in  the  word. 

In  papers  which  have  recently  been  read  before  medical  and  dental  societies 
in  regard  to  the  function  of  speech,  there  seems  to  be  no  recognition  of  distinguishing 
differences  between  the  sounds  of  the  letters  of  the  alphabet  and  the  sounds  of  the 
oral  elements  of  speech  of  which  the  letters  are  nothing  more  than  the  visual  sym- 
bols. While  all  the  vowel  elementary  sounds  are  similar  to  the  phonetic  sounds  of 
the  vowel  letters,  the  names  of  the  consonant  letters  when  written  or  spoken  are 
composed  of  two  or  more  oral  elements,  which  when  pronounced  may  have  very 
little  semblance  in  sound  to  the  oral  element  in  speech  which  this  letter  or  symbol 
stands  for. 

In  other  words,  in  pronouncing  the  names  of  the  letters  which  stand  for  the 
vowel  elements — a,  e,  i,  etc. — we  find  that  the  different  sounds  compare  favorably 
with  the  elementary  sounds  of  these  letters  in  speaking  the  words  in  which  they 
occur — except  in  diphthongs  and  silent  letters — because  the  naming  of  any  of  the 
vowels  is  in  itself  an  utterance  similar  to  their  phonetic  elemental  sounds  in  spoken 


42G  PART  IX.     THE  PROSTHETIC  CORRECTION  OF  CLEFT  PALATE 

words.  In  this  particular  they  (hlTcr  tjuitc  decidedly  from  the  luniics  (jf  the  conso- 
nants, each  one  of  which  requires  a  vowel  in  its  pronunciation,  and  in  the  spelling  of 
its  name,  as  be,  de,  te,  etc.  Therefore,  in  speaking  the  names  of  the  consonants,  we 
are  not  uttering  the  oral  elements  which  they  stand  for  in  words,  but  two  or  more 
oral  elements — thus  b  is  a  sudden  short  explosive  breath  sound,  bu,  added  to  a  vowel 
element,  e — otherwise  they  would  have  no  character  if  uttered  alone  as  do  the  vowels. 

Furthermore,  the  spoken  name  of  several  of  the  consonants  shows  little  or  no 
resemblance  to  the  oral  element  which  the  consonant  symbol  stands  for  in  speech. 
For  instance,  in  pronouncing  the  name  of  the  letter  h,  we  find  that  it  is  composed 
phonetically  of  two  oral  elements,  a  and  the  breath  emission  ch,  but  its  oral  clement 
in  the  words  horse,  house,  etc.,  is  an  open  aspirate  which  is  simply  a  forced  breath 
sound  made  at  the  back  of  the  mouth  or  in  the  throat,  and  quite  different  in  sound 
from  the  word  aich,  which  is  made  principally  at  the  front  of  the  mouth.  Again, 
in  the  phonetic  pronunciation  of  the  name  of  the  letter  w,  it  is  found  to  be  composed 
of  four  oral  elements,  du-bu-1-u,  which  in  combination  is  quite  unlike  the  open 
aspirate  oral  element  made  at  the  lips  which  the  symbol  stands  for  in  wood,  wet, 
etc.    Note  the  sound  that  is  emitted  before  it  starts  the  vowels  o  and  e. 

There  is  another  distinguishing  difference  between  vowels  and  consonants. 
Each  vowel  has  a  number  of  oral  elements  which  are  quite  distinctly  different 
phonetically  in  sound,  and  are  made  with  a  slightly  different  mechanism,  as,  a 
(ale),  a  (at),  a  (all),  a  (ah),  etc.;  whereas,  the  consonant  oral  elements  are  charac- 
terized by  a  single  sound  and  mechanism.  While  this  is  true  in  regard  to  the  mech- 
anism of  the  consonants,  there  is  an  apparent  difference  in  the  initial  and  final 
sound  of  a  number  of  them,  1,  r,  n,  m,  f ,  because  in  the  initial  they  always  join  the 
vowel  with  an  explosive-like  sound,  and  in  the  final,  the  organs  and  mechanism 
remain  in  the  set  position  until  the  sound  of  the  element  stops. 

Broadly  speaking,  the  vowels  are  the  body  or  framework  of  speech,  and  the 
consonants  are  the  finishing  touches  which  give  to  speech  its  sharply  defined 
characteristics.  The  vowels  are  the  open  voice  sounds,  and  the  consonants  are  the 
forced  breath  sounds,  and  while  the  latter  are  frequently  vocalized,  their  main 
function  is  to  give  distinct  enunciatory  quality.  In  order  to  understand  the  com- 
position and  mechanism  of  the  oral  elements  of  speech,  a  clear  conception  of  the 
distinctive  parts  of  speech  which  enter  into  their  formation,  together  with  the  dis- 
tinctive characters  of  physiologic  movements  and  positions  they  require,  is  of 

imperative  importance. 

The  Vowels 

The  Vocals,  or  Vowel  Oral  Elements,  whose  symbols  in  the  English  language  are 
a,  e,  i,  o,  u,  and  final  y,  are  those  utterances  which  impart  to  speech  its  main  voice 
tones;  and  whether  uttered  with  voice  or  whispers,  they  are  the  open  or  the  least 
interrupted  of  all  the  elementary  sounds  of  spoken  language.  They  are  character- 
ized by  the  different  forms  of  the  pharyngeal  and  oral  cavities  through  which  they 
pass  more  or  less  freely.    They  demand  for  their  perfection  of  tone  and  resonance  a 


CHAPTER  II.     PHYSIOLOGIC  AND  PHONETIC  PRINCIPLES  427 

complete  closure  of  the  oro-nasal  passage,  though  they  may  be  uttered  quite  dis- 
tinctly in  a  nasal  tone  by  all  cleft  palate  persons. 

While  the  vowel  sounds  seem  to  be  the  most  hopeful  parts  of  speech  to  correct 
in  the  preliminary  examination  of  a  cleft  palate  patient,  they  are  almost  invariably 
the  last  in  which  perfection  of  tone  is  acquired.  The  reason  for  this  is  evident.  The 
vowel  utterances  of  cleft  palate  pupils  are  at  first  so  much  more  perfect  than  the 
consonant  utterances,  that  they  are  given  little  thought  in  the  primary  efforts  to 
articulate  distinctly,  until  finally  when  quite  perfect  articulation  is  acquired,  we- have 
lingering  that  unpleasant  nasal  resonance  which  is  so  common  with  those  wearing 
vela  or  obturators  attached  to  plates,  or  those  with  surgically  corrected  palates. 
This  shows  (1 )  the  demand  in  vowel  utterance  of  an  absolute  closure  of  the  oro-nasal 
passage,  and  (2)  the  need  of  a  palate  which  will  have  the  voice-transmitting  proper- 
ties of  the  natural  palate. 

The  Consonants 

The  Consonant  Oral  Elements  are  the  forcible  breath  sounds  of  speech  produced 

by  forcing  the  unvocalized  air  blasts  through  more  or  less  constricted  openings,  or 

against  full  stops  to  be  suddenly  opened.   While  many  of  them  are  uttered  without 

voice,  others  are  intoned  by  vibrations  of  the  vocal  cords  from  the  very  start,  which 

finally  blend  into  the  true  sounds  of  the  vowel  tones.  They  give  to  spoken  language 

its  real  enunciatory  quality.    Under  normal  conditions  they  demand  for  distinct 

and  perfect  articulation  the  full  functional  involuntary  activity  of  the  velum- 

palati  to  completely  close  and  open  the  nasal  passage;  consequently  they  are  the 

most  difficult  for  persons  with  an  open  cleft  of  the  palate  to  utter  intelligibly. 

They  may  be  properly  classified  upon  the  basis  of  the  peculiar  character  of  sound 

which  is  made  in  their  perfect  utterance  by  an  open  and  by  a  complete  closure 

of  the  nasal  passage. 

Intrinsic  Value  of  Illustrations 

It  may  be  well  to  state  that  phonologic  illustrations  showing  positions  of  the 
tongue,  lips,  etc.,  in  different  movements  of  correct  articulation,  as  in  the  Classified 
Charts  herewith,  are  really  not  necessary  to  a  competent  teacher  who  speaks  dis- 
tinctly, except  that  it  may  aid  him  in  making  the  drawings  for  his  pupils,  showing  the 
proper  positions  for  the  utterance  in  which  they  fail.  Every  person  who  speaks  with 
accurate  articiilation  and  tone,  utters  each  oral  element  in  exactly  the  same  manner 
and  with  the  same  action  and  position  of  the  muscles  and  oral  organs  of  speech.  The 
sounds  may  differ  in  their  timbre,  their  melody,  and  their  resonating  quality,  but  each 
of  the  elementary  utterances  of  perfect  speech  is  always  made  with  the  same  mecha- 
nism ;  and  this  is  true  of  all  languages,  the  oral  elements  differing  as  the  languages 
differ.  If  the  teacher  or  anyone  is  capable  of  dividing  the  words  of  his  language  into 
their  oral  elements,  he  would  then  only  need  to  note  the  positions  and  form  of  the 
tongue  and  lips,  and  the  relation  they  bear  to  the  teeth  and  roof  of  the  mouth  in  utter- 
ing, first,  all  the  phonetic  sounds  of  vocals  or  vowels,  and  second,  in  uttering  all  the 
imvocalized  air  sounds,  unmixed  with  the  vocals,  which  constitute  the  consonants. 


428  PART   /.v.     /■///•;   PROSTHETIC  CORRECTION  OF  CLEFT  PALATE 

The  teacher,  tlierefore,  may  easily  make  the  required  drawings,  as  did  the  author 
when  niakin;^^  the  accompanying  charts,  witliout  reference  to  or  a  thought  of  other 
pubUshcd  illustrations,  commencing  at  the  front  of  the  mouth  and  going  back, 
i.  e.,  the  labials,  the  labio-dentals,  the  linguo-dentals,  and  the  linguo-palatals. 
The  author  has  adopted  this  same  order  in  placing  the  consonant  oral  elements  in 
the  classification  illustrated  by  the  Charts. 

Classification  of  Consonant  Oral  Elements 

In  a  classification  of  the  consonant  oral  elements  for  the  purpose  of  instructing 
those  who  may  be  called  upon  to  teach  cleft  palate  patients  to  speak  perfectly  after 
operations,  and  to  confine  the  work  to  purely  practical  methods  adapted  to  our 
purpose,  the  author  has  not  attempted  a  full  outline  of  all  the  elementary  sounds 
important  in  general  phonology  and  orthoepy,  the  main  object  being  to  base 
the  classification  upon  the  sotinds  requiring  the  perfect  functions  of  the  velum- 
palati,  of  which  these  pupils  have  hitherto  been  deprived — hoping  in  this  way  to 
enforce  the  acquirement  of  the  higher  possibilities  and  full  activities  of  the  velum- 
obturator,  or  of  the  surgical  palate.  A  more  extensive  and  erudite  endeavor  would 
only  serve  to  complicate  and  cloud  the  efforts  of  these  unfortunates,  whose  only 
object  is  to  learn  to  speak  distinctly,  and  who  therefore  are  not  supposed  to  acquire 
the  advanced  educational  principles  of  the  science  of  speaking  which  are  mainly 
intended  in  this  work  for  teachers,  or  those  who  it  is  hoped  will  undertake  the 
teaching  of  their  cleft  palate  patients,  and  who  therefore  should  fully  vmderstand 
the  basic  principles  of  phonology,  which  strictly  pertain  to  this  department. 

Slight  differences  between  the  sounds  and  mechanism  of  the  same  consonant 
oral  elements  uttered  by  dififerent  persons,  which  may  be  accjuired  by  association 
with  different  provincial  sovmds  of  the  vocals,  and  possibly  with  different  pro- 
vincial pronunciations,  have  always  rendered  it  impossible  for  authors  to  determine 
whether  certain  oral  elements  should  be  placed  in  one  class  or  the  other.  The  prin- 
cipal object  of  a  classification  to  a  pupil  whose  mechanism  has  always  been  deficient 
is :  that  different  sound  utterances  should  be  systematically  grouped  solely  on  the 
basis  of  their  phonation  and  mechanism,  so  that  they  will  aid  him  in  acquiring  not 
only  correct  sound-images,  but  the  manner  of  their  construction. 

The  special  classification  which  is  here  adopted  and  shown  by  the  charts  divides 
the  consonant  oral  elements  into  four  classes:  Nasals,  Explosives,  Open 
Aspirates  and  Explosive  Aspirates.  This  is  a  system  which  has  gradually 
developed  in  the  author's  practice  through  many  years  of  prosthetic  correction  of 
cleft  palate  and  the  subsequent  teaching  of  these  patients  to  speak.  It  is  made 
mainly  with  the  view  of  presenting  important  distinctions  between  the  sound- 
images  of  elements  whose  mechanism  is  quite  similar  and  consequently  difficult 
for  the  patient  to  acquire  without  special  drilling. 

This  has  particular  reference  to  certain  elements  in  "open"  and  "explosive" 
aspirates,  which  will  be  appreciated  when  one  distinctly  enunciates  the  initial  oral 


CHAPTER  II.     PHYSIOLOGIC  AND  PHONETIC  PRINCIPLES 


429 


elements  of  p  and  b  in  pay  and  bay,  and  w  and  wh  in  the  words  watt  and  what, 
each  pair  being  made  at  the  lips  with  exactly  the  same  positions  but  with  different 
breath  or  fricative  force.  Cleft  palate  pupils  who  may  easily  acquii'e  a  perfect 
articulation  of  the  initial  sounds  of  pu,  tu,  and  wa,  etc.,  will  often  work  for  weeks  on 
the  initial  sounds  of  bu,  da,  and  wh,  not  that  they  lack  in  physical  means,  but  they 
fail  to  acquire  a  fixed  and  retentive  conception  of  the  difference  in  the  sound- 
images,  when  uttered  by  themselves. 

In  this  connection,  note  the  explosive  and  open  aspirate  difference  in  the 
initial  and  final  1  and  r  in  the  words,  late  and  still,  and  run  and  bur,  showing 
the  necessity  of  dividing  the  Aspirates  into  two  Classes.  This  is  fully  explained  in 
the  explanatory  notes  following  the  Charts. 


Fig.  3. 


The  above  Chart  shows  the  position  o£  the  tongue, 
lips.  etc..  in  uttering  the  Nasal  Oral  Elements. 
Note  the  open  oro-nasal  passage. 


THE    NASALS 

The  Nasals  are  the  only  elements  of  speech 
in  which  the  oro-nasal  passage  is  required  to  be 
open  for  the  free  passage  of  the  air  blasts.  Nasals 
are  composed  of  the  intoned  consonant  sounds, 
m,  n,  and  ng,  which  it  will  be  found,  demand 
closed  stops  to  drive  the  column  of  vocalized 
breath  directly  into  the  nasal  chambers  for  the 
production  of  that  peculiar  nasal  resonance 
characteristic  of  these  utterances.  Therefore, 
they  are  the  only  sounds  which  most  patients  with 
open  clefts  will  perfectly  utter  with  proper  tone 
and  resonance.  The  resonance  and  enunciatory 
characters  of  each  of  the  nasal  elements  are 
regulated  by  the  points  at  which  the  stops  occur, 
and  which  determine  the  size  of  the  oral  cavity 
back  of  the  stop  as  a  part  of  the  resonating  area. 

The  Nasal  Oral  Elements  are  made  with  a 
sound  similar  to  musical  humming  tones,  but  of 
course  with  short  quick  action,  like  nearly  all 
oral  elements;  the  vocalized  breath  being  driven 
by  the  aid  of  the  full  stops  directly  into  the  nasal 
chambers. 

For  the  oral  element  which  the  symbol  m 
stands  for,  the  stop  is  formed  by  a  complete 
closure  of  the  lips.  In  the  word  mother  it  is  the 
sound  which  comes  before  other,  and  like  all 
the  nasals  it  ends  with  a  slight  explosive  as  it 
merges  into  the  vocal. 


430  PART   IX.     THE   PROSTHETIC  CORRECTfOX   OP  CLEFT  PALATE 

For  n,  the  slop  is  formed  by  a  complete  closure  at  the  end  and  sides  of  the 
tongue  against  the  anterior  part  of  the  hard  palate  and  along  the  gingival 
borders. 

For  ng,  the  stop  is  formed  by  a  closure  of  the  dorsum  of  the  tongue  against  the 
anterior  portion  and  sides  of  the  soft  palate. 

As  previously  stated,  in  the  advanced  stage  of  training  cleft  palate  pupils  to 
speak  a  nasal  resonance  running  into  and  destroying  the  true  resonance  of  con- 
necting vowels,  is  commonly  found  to  be  the  most  difficult  to  eradicate  of  all  the 
imperfections  of  their  speech.  This  is  largely  because  it  is  so  difficult  for  them  to 
overcome  the  habit  of  years  in  hearing  their  own  voice  utter  the  vowel  sounds 
with  the  passage  to  the  nose  open,  so  that  they  do  not  readily  cognize  the  difTerence 
between  the  true  resonating  tones  of  the  vowels  and  the  nasal  tones  which  they 
have  so  long  imparted  to  these  important  elements;  though  they  may  be  very 
cjuick  to  recognize  the  false  sounds  when  tittered  by  someone  else.  This  is  one  of 
the  most  marked  defects  which  almost  invariably  characterizes  the  speech  of 
cleft  palate  patients  whose  clefts  have  been  closed  surgically,  and  too,  for  the  very 
good  reason  that  it  is  impossible  for  them  to  completely  close  the  oro-nasal  passage 
with  a  surgically  constructed  velum,  however  perfect  the  operation.  Even  with 
patients  who  possess  perfect  velum-obturators,  and  whose  pharyngeal  and  palatal 
muscles  are  fully  capable  of  completely  closing  the  passage,  and  who,  moreover, 
will  perfectly  enunciate  all  the  phonetic  sounds  of  the  vowels  when  uttered  singly, 
will  still  unconsciously  allow  the  nasal  tone  to  characterize  many  of  their  vowel 
utterances.  This  is  particularly  true  of  vowels  which  immediately  precede  or  follow 
m  and  n,  and  which  demand  for  true  resonating  tone  that  the  nasal  resonance 
must  not  run  into  the  vowel  resonance;  indicating  that  the  normal  activity  of  the 
two  stops  which  regulate  these  two  sounds  and  their  immediate  harmonious  rela- 
tion must  work  with  lightning-like  rapidity.  For  instance,  at  the  very  instant  the 
nasal  stop  at  the  lips  and  tongue  is  opened  for  the  vowel  utterance  the  vowel  stop 
at  the  oro-nasal  passage  is  completely  closed,  and  vice  versa.  Whereas,  with  cleft 
palate  pupils  there  is  a  great  tendency  in  this  connection  to  keep  the  vowel  stop 
open. 

In  the  proper  pronunciation  of  the  word  mother,  note  the  slight  quick  hum 
of  the  m  with  its  nasal  quality  up  to  the  very  instant  that  the  lips  are  opened  with 
an  explosive-like  sound  in  starting  the  o.  Now  instead  of  making  a  firm  resonating 
utterance  of  the  o,  allow  the  velum  to  drop  with  passive  effort,  and  note  the  un- 
natural nasal  quality  that  is  immediately  imparted  to  the  vowel.  Again,  in  the 
proper  forcible  articulation  of  the  word  won't,  note  the  strong  resonating  quality 
of  the  vocal  element  o,  up  to  the  instant  that  the  end  of  the  tongue  claps  up  against 
the  roof  of  the  mouth  just  back  of  the  front  teeth,  with  the  production  of  that 
slight  nasal  hum  immediately  followed  by  the  sudden  breath  explosive  t,  which 
would  be  impossible  without  the  immediate  closure  of  the  velum  stop  at  the  very 
instant  the  tongue  is  released  from  the  nasal  element. 


CHAPTER  II.     PHYSIOLOGIC  AND  PHONETIC  PRINCIPLES 


431 


In  this  short  description  applied  to  the  nasals,  may  be  found  examples  of  training 
which  in  principle  apply  to  the  articulation  of  every  word  in  our  language,  and  the 
utterance  of  every  oral  element  in  the  four  classes  shown  by  the  Classified  Charts. 

The  competent  teacher  should  be  fully  capable  of  intelligently  analyzing 
his  own  speaking  activities,  not  only  as  regards  the  position  and  action  of  the 
organs  of  speech  in  correct  articulation,  bvit  in  the  psychologic  cognition  of  true 
sound-images.  This  will  enable  him  to  intelligently  impart  the  requisite  kind  of 
knowledge  to  his  pupils  as  an  indispensable  part  of  the  teaching  curriculum  of  the 
operation. 


THE   EXPLOSIVES 


Fig.  4. 


Explosives  are  the  elements  of  speech  which 
demand  qviite  a  pressiire  of  breath  back  of  a  full 
stop,  to  be  followed  immediately  with  a  sudden 
opening  of  the  stop  for  the  emission  of  the  com- 
pleted utterance  or  explosive,  which  may  occur 
at  the  beginning  or  ending  of  a  syllable  or  word. 

The  English  symbols  which  represent  the 
Explosive  Oral  Elements  are  b,  d,  c  (hard), 
g  (hard),  k,  p,  t,  th,  and  initial  y. 

For  the  purpose  of  definitely  symbolizing  the 
sounds  of  the  explosive  oral  elements  which  these 
letters  stand  for  in  words,  the  author,  as  before 
mentioned,  has  chosen  the  short  sound  of  a  and 
u — pronounced  uh  with  a  short,  quick  utterance 
— to  complete  the  symbol,  because  its  utterance 
comes  nearer  than  any  other  one  sound  in  rep- 
resenting the  completed  explosive  when  uttered 
alone.  When  the  explosive  oral  elements  are  thus 
phonetically  symbolized  and  arranged  respective- 
ly as  regards  positions  and  mechanism  of  utter- 
ance from  the  front  to  the  back  of  the  mouth, 
they  are  as  follows : 

For  bu  as  in  boy,  pu  as  in  pull,  the  stop  occurs 
between  the  lips. 

For  va  as  in  vain,  between  the  lower  lip  and 
upper  front  teeth. 

For  thti  as  in  the,  those,  etc.,  between  the 

flattened   end   of   the   tongue   and   upper   front 

teeth. 

For  du  as  in  do,  tu  as  in  take,  ku  or  cii  (hard)  as  in  Kate,  call,  etc.,  and  gu 

(hard)  as  in  go,  the  stops  occur  between  the  tongue  in  various  positions  and  points 


The  above  Chart  shows  the  position  of  the  tongue, 
Ups.  etc..  in  uttering  the  Explosive  Oral  Elements. 
Note  the  closed  oro-nasal  passage. 


432  I'AKr   IX.     rilE   PROSTHETIC  CORRECTION   OE  CLEFT   PALATE 

on  the  roof  of  the  mouth  from  the  front  teeth  to  the  middle  of  the  soft  palate. 
These  positions  and  points  will  be  somewhat  varied  with  different  individuals. 

The  illustrations  under  Explosives  show  the  position  of  the  oral  organs  and 
stops  at  the  start  of  the  utterance.  Where  two  positions  of  the  tongue  are  shown, 
the  one  indicates  its  position  at  the  tip  end  when  the  stop  occurs  to  start  the  ex- 
plosive element,  and  the  other  shows  the  position  which  immediately  follows,  to 
complete  its  full  utterance. 

The  Explosive  and  Aspirate  Oral  Elements  are  among  the  most  difficult  for 
cleft  palate  pupils  to  enunciate  distinctly.  This  is  not  surprising  when  one  re- 
members that  the  proper  placing  and  utterance  of  all  breath  sounds  requiring  full 
stops  and  small  constricted  channels  made  at  the  front  of  the  mouth,  have — with 
rare  exceptions — never  been  fully  accomplished  Ijy  them.  The  most  of  these  patients 
know  al:)solutely  nothing  about  placing  and  shaping  the  tongue  in  the  titterance 
of  the  greater  proportion  of  these  sounds;  and  in  their  efforts  they  will  handle  the 
tongue  with  a  degree  of  awkwardness  indicative  of  a  complete  lack  of  mental  control. 
Often  they  will  never  arrive  at  the  correct  movement  except  through  an  involun- 
tary action  of  the  muscles  in  eft'orts  to  imitate  the  sound-image.  When  they  have 
acquired  the  proper  sounds  by  repeated  eft'orts  with  the  aid  of  the  teacher,  they 
should  be  required  to  practice  these  isolated  sound  elements  with  a  short,  sharp, 
distinct,  forcible  utterance  before  attempting  to  pronounce  the  words  in  which  they 
occur.  When  this  is  perfectly  acquired,  they  may  then  be  joined  to  all  the  long  vocal 
sounds  of  the  vowels,  as  ba,  be,  bf,  b5,  bu,  etc. — connecting  the  explosive  sound 
elements  with  all  the  phonetic  sounds  of  each  of  the  vowels.  These  sounds  should 
never  be  practiced  at  first,  except  in  the  presence  of  the  teacher,  or  until  the  sound- 
image  is  acquired. 

Often  it  will  be  found  that  pupils  will  immediately  and  correctly  connect  the 
explosive  with  one  sound  of  a  vocal,  while  with  other  phonetic  sounds  of  the  same 
vowel  they  will  require  practice  for  days  and  even  nionths — as  instanced  by  the 
patient  who  rapidly  acquired  the  ability  to  utter  distinctly  most  of  the  elementary 
sounds,  but  who  practiced  for  weeks  before  he  was  able  to  properly  join  the  ex- 
plosive tu  to  o  in  toe,  or  oo  in  too,  though  he  was  able  to  perfectly  make  both  oral 
elements  separately.  In  these  cases,  the  practice  consists  in  drawing  the  separated 
sounds  closer  and  closer  together  until  they  merge  into  each  other.  Pupils  will 
frequently  soon  learn  to  enunciate  perfectly  certain  oral  elements  singly,  but  which 
require  days  of  practice  to  smoothly  unite  into  words.  Thus,  ya,  and  the  sibilant 
s  in  yes,  will  sound  like  yets.    Again,  fe  and  sh  in  fish  will  he  more  like  fitch,  etc. 

It  will  be  observed  that  in  some  of  the  oral  elements  the  initial  explosive  sound 
is  started  with  the  voice  or  vocalized  breath,  as  d\x  in  day ;  while  with  other  explosive- 
like sounds,  as  initial  f,  it  starts  with  the  expelling  of  un vocalized  breath  but  ends 
with  a  distinct  explosive  as  it  joins  the  vocal  in  fu,  fall.  This  is  an  example  of  many 
fine  distinctions  in  the  enunciation  of  the  explosives,  the  teaching  of  which  possibly 
has  not  been  found  necessary  in  the  general  teaching  of  pupils  with  ordinary  defects. 


CHAPTER  11.     PHYSIOLOGIC  AND  PHONETIC  PRINCIPLES  433 

But  its  recognition  and  application  is  nevertheless  of  very  great  importance  in 
teaching  those  who  have  never  made  a  correct  approach  to  distinctness  in  ex- 
plosive and  aspirate  utterances.  It  is  partly  this  which  led  the  author  to  divide 
Aspirates  into  the  "Open"  and  "Explosive"  Classes. 

With  all  initial  explosive  sounds,  uttered  with  perfect  distinctness,  there 
invariably  occurs  a  more  or  less  sudden  liberation  of  the  utterance  before  it  joins 
the  vocal.  This  plainly  indicates  preliminary  accumulation  of  compressed  breath 
back  of  a  full  stop,  which  could  only  be  possible  with  the  palatal  passage  completely 
closed.  With  certain  explosive  oral  elements,  however,  the  explosive  sound  is  almost 
imperceptible,  because  it  is  drowned  by  the  aspirate  part  of  its  utterance,  as  in 
initial  f,  1,  ch,  in  fate,  late,  choose,  etc.  This  has  led  authors  to  classify  these 
utterances  solely  under  "Aspirates,"  and  also  because  when  used  as  finals  they  are 
clearly  open  aspirates.  But  inasmuch  as  it  is  found  that  the  distinctive  part  of  the 
utterance  which  cleft  palate  pupils  fail  to  make  is  the  explosive  part,  or  the  part 
which  demands  a  sudden  liberation  of  compressed  breath,  however  inaudibly  it  is 
sounded,  they  are  placed  in  our  classification  under  "Explosive  Aspirates,"  because 
it  is  so  important  in  our  teaching  that  phonetic  differences  should  be  sharply 
defined,  and  that  we  should  not  be  obliged  to  cling  to  a  classification  that  is  in- 
adequate in  our  field  of  orthoepy,  however  well  established  it  may  be  phonologically. 

While  it  is  possible  in  seemingly  well  spoken  language  that  certain  oral  elements, 
which  should  have  distinct  explosive  utterance,  are  slurred  into  sounds  more  like 
aspirates  without  special  notice,  nevertheless  in  teaching  pupils  who  have  never 
intelligibly,  or  at  least  distinctly,  uttered  these  sounds  or  employed  the  proper 
methods,  the  author  believes  it  to  be  imperative  that  the  sharp  and  distinct  utter- 
ance of  these  elements,  especially  those  with  stops,  should  be  insisted  upon.  One 
of  the  main  reasons  for  this  particular  kind  of  training  is  that  it  is  the  only  way 
in  which  the  undeveloped  muscles  in  conjunction  with  the  obturator  can  be  taught 
to  involuntarily  close  the  oro-nasal  passage.  In  the  continued  eftorts  toward  this 
accomplishment  the  inhibited  growth  and  dormant  activities  of  the  palatal  and 
pharyngeal  muscles,  through  lack  of  use,  will  become  revivified  and  no  doubt  stim- 
ulated toward  assuming  their  normal  inherited  properties  and  proportions. 

Again  in  correct  speech  in  pluralized  words  having  final  explosives,  the  explosive 
termination  of  the  element  is  not  sounded  but  is  lost  in  the  sibilant,  as  in  cats,  etc. 

THE  ASPIRATES 

The  Aspirates  are  the  parts  of  speech  uttered  with  a  forcible  expulsive  or 
fricative  emission  of  the  breath  through  a  constricted  opening.  They  are  character- 
ized by  the  form  of  the  opening  and  oral  channel  through  which  the  breath  is 
forced,  and  a  variety  of  muscular  actions  which  render  them  quite  distinctive  in 
the  quality  and  character  of  their  utterance.  The  sounds  of  the  aspirate  oral 
elements  may  be  divided  into  "Open"  Aspirates  and  "Explosive"  Aspirates. 


434 


/MA'7'   IX.     THE  PROSTHETIC  CORRECTION   OF  CLEFT  PALATE 


Sh — shame 


L — still,  similar  to  la 
R — bur,  similar  to  ru 


Open  Aspirates 

P"'-  •"'•  'J'hc  Open  Aspirate  elements  are  continuous 

sounds,  mostly  voiceless  breath  sounds,  with  no 
abrupt  or  explosive  beginning  or  ending,  and 
blend  evenly  into  the  vowel  tones  to  which  they 
arc  joined.  The  English  symbols  which  represent 
the  open  aspirate  elements  are  c  (soft),  f,  h, 
1  (final),  r,  s,  sh,  wh,  z,  and  x  (final).  When 
phonetically  symbolized  and  arranged  respectively 
as  regards  position  and  mechanism  of  utterance 
they  are  as  follows : 

In  the  utterance  of  wh  as  in  when,  what, 
etc.,  the  breath  blast  emission  is  at  the  lips. 

In  f  (final)  as  in  half,  stiff,  etc.,  between  the 
lower  lip  and  upper  teeth. 

In  c  (soft),  s  and  z,  as  in  cell,  so,  zeal,  etc., 
at  the  tip  end  of  the  tongue  and  anterior  palatal 
surface. 

In  sh  as  in  shame,  show,  etc.,  between  the 
Ijroadened  blade  of  the  tongue  and  anterior  hard 
palate. 

In  1  (final)  as  in  still,  etc.,  see  fuller  explana- 
tion under  "Notes  relative  to  the  Chart." 

In  r  (final)  as  in  for,  fur,  etc.,  between  the 
soft  palate  and  dorsum  of  the  tongue  with  de- 
pressed blade. 

In  h  as  in  her,  horse,  etc.,  between  the  dorsum 
of  the  tongue  and  contracted  throat  muscles. 

The  pure  sibilants  s,  c,  and  x  (final),  consist 
of  a  fine  sharp  whistle,  made  as  shown,  through 
a  tiny  opening  at  the  tip  end  of  the  tongue. 
The  lower  figure  shows  the  contact  linguo-palatal 
area.  While  in  ordinarily  correct  speech,  the 
sibilant  is  a  fricative  or  hissing  sound,  the  author 
considers  it  ciuite  important  that  cleft  palate  pupils  should  learn  to  make  the 
phonetic  high  clear  thin  whistle  at  the  tip  of  the  tongue  which  is  laid  down  in 
all  phonologies  as  the  perfect  sibilant  sound.  Nothing  adds  so  much  to  the  per- 
fection of  speech  and  its  distinctive  characterization  as  this  sound  when  properly 
and  distinctly  made  and  which  forms  such  an  important  part  of  our  spoken 
language. 

Z,  the  cognate  of  s,  is  the  same  with  the  addition  of  vocalization,  the  vibrations 
of  which  can  be  felt  in  the  throat. 


Ha,— hat 


F, — cuff,  similar  to  va 


The  above  C'hart  sho  ws  the  position  of  the  tongue, 
lips.  etc..  in  utterin  g  the  Open  Aspirate  Elements, 
Note  the  closed  oro-nasal  pas.=;age. 


CHAPTER  U.    PHYSIOLOGIC  AND  PHONETIC  PRINCIPLES 


435 


Fig.  6. 


Sh  is  made  by  forcibly  expelling  the  breath  through  a  broad  thin  opening  be- 
tween the  retracted  end  of  the  tongue  and  anterior  alveolar  ridge,  with  the  lips 
pushed  forward  as  a  part  of  the  characterization  of  the  sound. 

Ch,  J,  G.  With  the  explosive  aspirate  ele- 
ments, ch,  j,  and  soft  g,  the  second  and  main 
position  of  the  tongue  following  that  of  the  par- 
tial explosive  is  similar  to  that  of  sh,  but  with  no 
special  action  of  the  lips. 

L.  Note  the  difference  in  the  mechanism  of  1 
hnal  and  1  initial.  With  the  former,  or  open  aspi- 
rate sovmd  ul,  as  in  full,  the  element  is  completely 
ended  while  the  end  of  the  tongue  rests  against 
the  upper  alveolar  ridge,  the  vocalized  breath 
escaping  at  both  sides  of  the  tongue;  whereas,  in 
the  explosive  aspirate  lu  as  in  lot,  the  aspirate  part 
of  the  element  is  made  in  the  same  way,  but  is 
interrupted  by  a  sudden  dropping  of  the  end  of  the 
tongvie  to  emit  the  explosive  to  join  the  vowel 
clement.    (See  La,  under  explosive  aspirates.) 

R.  The  open  or  aspirate  part  of  the  sound  of  r 
as  in  bur  is  made  by  forcing  the  vocalized  breath 
through  a  somewhat  constricted  opening  at  the 
dorsum  of  the  tongue  and  on  over  its  concaved 
surface,  the  sides  and  tip  being  slightly  raised. 
In  the  explosive  aspirate  ru  as  in  run,  the  r  sound 
is  intciTupted  by  the  end  of  the  tongue  momen- 
tarily approaching  the  roof  to  prodvice  a  more 
forcible  and  sudden  emission. 

The  mechanism  of  the  other  oral  elements 
is  well  shown. 

The  Explosive  Aspirates 

The  Explosive  Aspirate  elements  are  those 
which  are  uttered  with  a  somewhat  sudden 
expelling  of  the  breath,  not  unlike  explosives,  as 
it  joins  the  vocal,  though  the  principal  part  of 
the  sound  is  aspirate.  The  difference  between 
open  and  explosive  aspirates  will  be  recognized  in  pronouncing  when  and  went. 

The  English  symbols  which  represent  the  "explosive  aspirate"  elements  are 
ch,  f,  g  j,  1  (hard ),  q,  r,  w,  and  initial  y.  Arranged  respectively  as  regards  position 
and  mechanism  of  utterance  they  are  as  follows: 

In  w,  as  in  watt,  was,  etc.,  the  emission  occurs  at  the  lips. 


The  above  Chart  shows  the  position  of  the  tongue, 
lips,  etc.,  in  uttering  the  Explosive  Aspirate  Ele- 
ments. 

Note  the  closed  oro-nasal  passage. 


43()  PART   IX.     THE  PROSTHETIC  CORRECTION   OE  CLEFT  PALATE 

In  f  (initial),  as  in  few,  fur,  etc.,  between  lower  lip  and  teeth. 

In  1  (initial),  as  in  late,  lot,  etc.,  at  the  sides  of  the  tongue  with  the  end 
touching  the  anterior  alveolar  ridge. 

In  ch,  as  in  church,  g  (soft),  and  j,  as  in  George  and  James,  l)ctween  the 
flattened  blade  of  the  tongue  and  the  anterior  palatal  surface. 

In  q,  as  in  quick,  between  the  dorsum  of  the  tongue  and  the  soft  palate. 

In  r  (initial),  as  in  run,  rat,  etc.,  same  as  the  open  aspirate  r,  except  that  the 
end  of  the  tongue  is  brought  into  contact  with  the  palatal  surface  to  start  the 
sound. 

In  (initial)  y,  as  in  yet,  yoke,  etc.,  between  the  soft  palate  and  dorsum  of  the 
tongue  with  end  depressed. 

The  position  and  form  of  the  lips  in  the  utterance  of  a  large  proportion  of  the 
oral  elements  are  quite  as  important  in  characterizing  the  articulate  sound  as 
the  form,  position,  and  relation  of  the  other  organs  which  enter  into  the  con- 
struction of  the  elements.  In  this  connection  it  should  be  remembered  that  cleft 
palate  patients  or  pupils,  before  operations,  have  rarely  and  sometimes  never 
used  the  lips,  the  teeth  and  lips,  or  the  end  of  the  tongue,  in  a  speaking  func- 
tional sense;  therefore,  special  instruction  with  the  positions  definitely  defined 
should  be  given  by  the  teacher  with  an  insistence  that  they  be  fully  carried  out  in 
their  practice,  even  to  a  pronounced  degree  at  first. 

The  teacher  should  verify  all  the  muscular  positions  shown  here  and  elsewhere, 
in  uttering  the  different  oral  elements  of  the  consonants,  in  order  to  teach  the  pupil 
the  correct  positions  by  practical  instruction  and  illustrations. 


CHAPTER  III 

THE   TECHNIC   CONSTRUCTION   OF   THE   \ELUM-OBTURATOR 


The  Impression  and  Model  of  the  Cleft 

With  an  understanding  of  the  physiologic  functions  of  the  normal  organs  of 
Speech,  one  cannot  fail  to  recognize  the  requirements  that  are  necessary  in  an 
instrument  which  is  calculated  to  restore  vocal  articulation  and  resonance  to 
congenital  cleft  palate  patients.  The  most  important  technic  requirements  of  this 
accomplishment  lie  (1),  in  obtaining  an  accurate  adequate  impression,  and  (2), 
in  forming  the  veil  of  the  obturator. 

The  impression  is  not  taken  by  placing  plaster  in  a  prepared  tray  and  forcing 
the  mass  into  place,  as  in  prosthodontia,  but  most  of  the  impression  is  made  by 
carrying  the  plaster  into  place  a  little  at  a  time  on  the  tip  end  of  a  spatula.  This 
necessitates  a  jelly-like  consistency  of  the  plaster,  a  condition  which  is  obtained 
with  some  of  the  best  slow-setting  plasters  by  thoroughly  stirring  the  proper  mix, 
and  not  by  mixing  it  thin  and  waiting  for  it  to  partially  set.  A  perfect  impression 
of  the  required  portion  of  the  floor  of  the  nares  is  impossible  in  any  other  way. 
It  is  also  necessary  that  the  nasal  portion  of  the  impression  should  easily  separate 
at  the  cleft  from  the  lingual  portion,  otherwise  it  could  not  be  removed;  all  of  this 
will  be  fully  explained. 

A  perfect  plaster  impression  of  an  ordinary  typical  cleft  for  the  velum-obturator 
requires  no  more  skill  than  ordinary  impressions  for  partial  and  full  dentures, 
which  skillful  dentists  obtain  daily.  It  is  necessary  that  the  working-model 
(Figs.  19  and  20)  from  the  impression  should  duplicate  only  the  hard  parts  on  the 
lingual  and  nasal  surfaces  of  the  palatal  process  where  the  body  of  the  obturator 
should  exactly  fit  (Fig.  7).  The  lingual  lateral  wings  of  the  obturator  should  ex- 
tend no  farther  laterally  and  anteriorly  upon  the  roof  of  the  mouth  than  is  re- 
quired to  correct  the  curve  of  the  dome  of  the  arch  for  speaking  purposes,  and  give 
security  to  the  obturator  without  impairing  its  mobility. 

The  nasal  extensions,  shown  on  the  right  in  Fig.  7,  should  fit  the  floor  of  the 
nares  over  a  sufficient  area  to  prevent  not  only  the  body  of  the  obturator  from  drop- 
ping directly  down  when  in  position,  but  to  prevent  the  possibility  of  its  dropping 
at  all  ;(;////  //  has  passed  directly  hack  along  the  floor  from  H  to  %  of  an  inch.  In 
connection  with  this,  if  the  velum  of  the  obturator  has  the  proper  form  and  rela- 
tive position,  as  will  be  described,  the  involuntary  action  of  the  palatal  and  pha- 
ryngeal muscles  will  not  only  prevent  it  from  falling,  but  will  at  once  force  it  back 
to  place,  if  it  starts  to  become  dislodged. 

437 


438 


PART   /.v.     •/•///•:   PROSTHETIC  C()RRECTH)\   OF  CLEFT   PALATE 


Before  taking  tlie  impression,  the  mental  and  physieal  sensitiveness  of  the 
tissues  should  be  dulled.  If  the  throat  muscles  are  exceedingly  sensitive,  with 
tendencies  to  contract  or  gag  upon  the  slightest  touch,  as  they  commonly  are,  they 
should  be  freely  manipulated  with  the  finger,  a  brush,  or  an  instrument,  until  this 
is  reduced  and  the  patient's  fears  wholly  allayed.     This  may  require  more  than 


Vu, 


On^the  left  is  an  oral  view,  1st,  of  a  typical  cleft;  2d,  the  velum-obturator  in  position;  3d,  the 
velum-obturator.     On  the  right  are  the  nasal  aspects. 

one  sitting.    The  author  has  never  found  it  necessary  to  anesthetize  the  tissues, 
though  there  is  no  special  objection  to  it. 

As  a  part  of  this  preliminary  diagnosis,  the  operator,  with  electrical  mouth 
lamp  and  light  rubber  or  celluloid  probes  bent  at  different  angles — which  can  be 
easily  made  from  knitting  needles — should  become  thoroughly  acquainted  with 
all  the  physical  conditions:  the  cleft,  the  floor  of  the  nares  and  its  lateral  recesses, 
if  any,  and  all  irregularities  arising  from  unusual  adhesions.     The  examination 


CHAPTER  in.     TECHXIC  CONSTRUCTIOX  OF   VELUM-OBTURATOR 


439 


should  particularly  pertain  to  the  form  and  surfaces  of  the  inferior  meatus  over 
which  the  nasal  portion  of  the  obturator  is  to  extend,  in  order  to  determine  if  this 
portion  of  the  impression  is  to  be  taken  in  one  or  two  sections,  to  prevent  the  possibil- 
ity of  getting  it  dovetailed  in  this  cavity.  In  the  normal  state,  the  lateral  walls 
at  the  points  of  entrance  to  the  nares  from  the  naso-pharynx,  are  often  more  or  less 
constricted  or  drawn  in  toward  the  median  line,  which  would  prevent  this  portion 
of  thQ  impression,  if  taken  in  one  piece,  from  being  forced  back  sufficiently  to  drop 
out  of  the  cleft.  Occasionally,  the  vomer  is  united  to  one  border  of  the  cleft,  pre- 
senting complications  that  will  be  described  later. 

This  would  also  be  a  favorable  time  to  commence  the  study  of  the  positions 
and  action  of  the  palatal  and  pharyngeal  muscles,  and  also  the  walls  of  the  pharynx 
with  the  muscles  relaxed  and  contracted  along  the  zone  to  be  selected  for  the  posi- 
tion and  extent  of  the  rim  of  the  veil  of  the  obturator. 


Fig.  S. 


Small  Clefts 

Impressions  of  small  clefts  (Fig.  8)  which 
extend  onh*  through  the  soft  palate,  or  those 
which  extend  no  more  than  a  half-inch  into  the 
hard  palate,  are  usually  far  more  difficult  to 
obtain  than  those  of  larger  clefts,  because  it  is 
difficult  to  prevent  starting  involuntary  mus- 
cular contractions,  by  the  required  movements 
of  the  spatula  when  introducing  th'e  plaster. 
These  should  always  be  allowed  to  subside 
before  further  steps  are  taken. 

It  should  be  remembered  that  the  object 
of  the  impression  in  every  case  is  principally 
to  ()l>tain  an  exact  reverse  duplication  of  the 
hard  nasal  floor,  sufficiently  far  forward  and 
laterally,  to  sustain  the  body  of  the  obturator; 
in  the  same  manner  as  will  be  described  for 
.M.  left  of  the  soft  palate  or  veium-p^iL^t..  largcr  clcfts ;  aud  that  no  attempt  should  be 

made  to  obtain  an  exact  impression  of  any  part  of  the  bifurcated  velum. 

If  a  sufficiently  extensive  impression  can  be  taken  of  the  floor  of  the  nares, 
whether  for  small  or  large  clefts,  there  is  no  reason  why  an  obturator  for  one 
should  not  be  worn  quite  as  successfully  as  for  the  other,  without  a  svistaining 
device,  and  consequently  with  perfect  restoration  of  speech  capabilities;  providing 
of  course  that  the  most  scientific  part  of  the  work  on  the  veil  of  the  palate  is  prop- 
erly performed.  This  statement  is  well  attested  in  the  author's  practice  with 
congenital  clefts  of  almost  every  character  and  size. 

The  case  shown  in  Fig.  8  arose  in  practice  before  the  days  of  the  present  ob- 
turator, and  is  the  smallest  congenital  cleft  that  the  author  has  ever  attempted  to 


MO  /MA'/'   /.v.     /■///■;   PROSTHETIC  CORRECTION   OF  CI. EFT   PALATE 

correct.  The  operutiun  for  its  correction  consisted  of  a  soft  rubber  artificial  velum 
buttoned  to  a  thin  narrow  very  flexible  platinum-gold  ribbon  which  extended  from 
a  narrow  plate  across  the  roof  of  tlie  mouth  sustained  witli  clasps  around  the  first 
molars.  The  nasal  portion  of  the  obturator  was  limited  and  yet  sufficient  to  sustain 
it  in  place  when  held  forward  by  the  plate.  Its  veil  was  similar  to  the  Kingsley 
vela.  This  of  course  required  frequent  renewals,  because  of  the  rapid  deterioration 
of  the  soft  rubber.  One  of  the  objectionable  features  in  the  employment  of  soft 
rubber  vela  is:  patients  will  not  have  them  renewed  as  they  should. 

In  the  construction  of  the  present  form  of  obturators  for  very  small  clefts, 
where  there  is  a  possibility  of  its  falling  into  the  grasp  of  the  swallowing  muscles, 
it  is  always  advisable  to  start  the  patient  with  a  sustaining  device  similar  to  that 
described,  though  the  author  is  confident  this  will  be  found  unnecessary,  when  the 
muscles  become  educated  in  sustaining  its  position.  One  of  the  greatest  advantages 
in  this  particular  with  the  hard  rubber  obturators  is  its  extremely  light  weight. 

The  sustaining  device  should  not  be  firmly  buttoned  to  the  obturator  with  the 
view  of  carrying  both  into  place  together,  but  the  posterior  end  of  the  retainer  should 
be  bent  in  the  form  of  a  hook  that  will  drop  into  its  fitted  place  after  the  obturator 
has  been  inserted. 

In  taking  the  impression  of  a  very  small  cleft  for  an  obturator,  it  may  be 
possible  to  extend  the  plaster  further  forward  on  the  floor  of  the  nares  than  it 
may  be  found  practical  or  advisable  to  extend  the  nasal  portion  of  the  obturator. 
This  extension  on  the  model,  however,  should  be  preserved  and  duplicated  in  the 
metal  casts,  as  it  may  be  found  useful  later.  Besides  the  nasal  portion,  the  working 
model  must  also  duplicate  the  required  hard  palatal  surface,  and,  moreover,  the 
two  surfaces — the  nasal  and  the  palatal,  for  both  small  and  large  clefts — must  bear 
exact  impressional  relations  to  each  other.  This  is  not  possible  if  the  nasal  section 
has  been  ever  so  slightly  raised  from  its  seating,  or  if  the  sections  have  not  been 
exactly  readjusted  outside  of  the  mouth. 

This  is  not  a  very  difficult  feature  with  larger  clefts,  as  will  be  shown;  nor 
would  it  be  difficult  with  small  clefts  if  the  plaster  could  be  properly  introduced 
with  a  spatula  and  permitted  to  retain  its  position  while  a  sufficient  quantity  is 
added  and  brought  down  through  the  cleft  to  make  a  reliable  broad  bearing  joint 
with  the  palatal  section. 

Where  this  is  not  possible,  the  impression  may  be  taken  by  the  use  of  a  special 
tray.  If  a  tray  is  employed — the  form  of  which  in  certain  essential  particulars 
must  of  necessity  be  left  to  the  ingenuity  of  the  operator — as  no  two  cases  are 
alike — it  should  be  of  that  character  to  enable  passing  it  back  far  enough  to  then 
quickly  carry  it  upward  and  forward  into  place,  and  of  a  form  to  hold  sufficient 
plaster  to  be  forced  over  the  floor  of  the  nares. 

The  cup  of  the  tray  (Fig.  9)  may  be  made  of  block  tin  that  can  be  easily  bent 
to  curve  forward  over  the  bifurcated  velum-palati  and  palatal  process.  To  this, 
firmly  soft-solder  a  No.  9  nickel-silver  wire  handle,  as  shown.  The  cup  portion  may 


CHAPTER   III.     TECUXIC  CONSTRUCTION   OF    VELUM-OBTURATOR 


441 


be  further  extended  with  a  thin  sheet  of  wax  and  carried  into  place  while  it  is  soft ; 
this  should  leave  plenty  of  room  for  the  plaster,  and  avoid  forcing  the  yielding 
tissues  too  far  out  of  place.  Though  this  is  of  little  importance,  as  the  duplicated 
uvula  and   softer  portion  of   the  velum-palati,  whatever  their  positions,  are  cut 


Fig.  9. 


away  on  the  model.  The  illustration  shows  a  cross-section  of  the  tray  in  position. 
It  will  be  noticed  that  the  wire  handle  leaves  sufficient  space  for  placing  the  lingual 
portion  with  a  spatula. 

When  the  tray  and  plaster  are  carried  to  place,  allow  the  handle  to  rest  upon 
the  incisor  teeth  to  firmly  steady  it,  and  maintain  this  position  while  the  second  or 
lingual  section  is  introduced  and  hardened. 

In  those  cases  of  non-imtability  of  the  soft  palate,  or  when  cocainized,  the 
introduction  of  the  tray  containing  the  plaster  may  be  immediately  preceded  by 
first  introducing  considerable  plaster  above  the  cleft  with  the  spatula,  as  in  larger 
clefts.  This  will  insure  obtaining  a  more  extensive  impression  of  the  nasal  floor. 
A  large  mouth -mirror  should  be  held  back  of  the  plaster  so  as  to  prevent  it  after  it 
leaves  the  spatula,  from  falling  from  its  lodgment  into  the  throat.  If  a  sufficient 
mass  of  the  plaster  can  be  forced  in  this  way  forward  of  the  attachment  of  the  velum- 
palati,  it  will  retain  its  position  and  thus  eliminate  the  need  of  introducing  so  much 
on  the  tray,  which  may  therefore  be  reduced  in  size.  After  the  plaster  has  set,  there 
should  be  no  special  difficulty  in  carrying  it  backward,  downward,  and  out  of  the 

mouth. 

Two-Section  Impression 

For  the  ordinary  typical  cleft,  or  those  similar  to  Figs.  1  and  7,  which  extend 
well  into  the  hard  palate,  but  not  forward  of  the  commencement  of  the  alveolar 
process,  the  nasal  section  can  usually  be  taken  in  one  piece,  providing  it  is  found 
upon  examination  there  is  no  obstruction  which  will  prevent  the  impression  from 
being  easily  forced  back  and  out  upon  its  removal.  The  head  of  the  patient,  for  all 
cleft  palate  impressions,  should  not  be  thrown  back  any  farther  than  is  absolutely 
necessary  to  obtain  ease  of  manipulation.   The  plaster  being  well  stirred,  but  noth- 


442  PART   /.v.     /■///•;    I'ROSTlllVriC  COKKIiCTIUN   OF   CLEFT   I'ALATE 

ing  added  to  hasten  its  setting,  may  be  rapidly  and  deftly  inlrodueed  from  the  point 
of  a  spatula — being  carefnl  to  not  arouse  the  sensitive  activity  of  the  soft  palate. 

The  spatula  should  be  about  a  half-inch  wide  and  squared  at  the  end  with  cor- 
ners and  edges  rounded  so  as  to  avoid  injuring  the  mucous  membranes,  and  formed 
to  carry  as  much  plaster  as  possible  at  the  very  end  past  the  border  of  the  cleft. 
The  plaster  should  be  of  that  slow-setting  gelatinous  consistency  that  will  enable 

Fig.  10. 


lifting  a  goodly  quantity  on  the  end  without  sliding  oft"  the  spatula.  Introduce  it 
into  the  nasal  cavity  one  side  at  a  time,  and  scrape  if  off  the  spatula  on  the  edge  of 
the  cleft  forward  of  the  velum  and,  by  rapid  additional  introductions  which  will 
act  as  followers,  the  plaster  can  be  forced  back  along  the  floor  of  the  nares  to  the 
fullest  extent. 

Complete  one  side  before  going  to  the  other.  Then  fill  the  central  portion  and 
level  it  between  the  cleft  along  a  line  which  represents  its  nearest  approaching 
borders;  finally,  remove  all  superfluous  plaster  adhering  to  the  lingual  surface. 
In  this  first  part  of  the  operation,  great  care  should  be  exercised  so  as  not  to  start 
the  contracting  activities  of  the  muscles.  There  is  always  plenty  of  time  with  one 
batch  of  slow-setting  plaster,  if  moderately  rapid  movements  are  made.  If  a  par- 
ticle is  allowed  to  drop  into  the  throat,  or  on  to  the  tongue,  it  should  at  once  be 
removed.  Or  if  the  plaster  is  carried  or  is  allowed  to  float  back  on  the  upper 
lateral  borders  of  the  velum,  as  may  arise  in  an  endeavor  to  obtain  an  impression 
of  the  posterior  lateral  surfaces,  it  is  very  liable  to  cause  gagging  and  destroy  the 
impression. 

The  exposed  portion  of  the  nasal  section  between  the  borders  of  the  cleft 
is  now  thoroughly  lubricated  with  a  soft  camel's  hair  brush,  and  another  batch  of 
plaster  is  brought  and  carefully  spread  over  it  and  on  to  the  roof  of  the  mouth  with 
a  spatula,  and  continued  out  even  with  the  linguo-occlusal  surfaces  of  the  teeth. 
See  Fig.  10.  Or  the  first  lingual  portion  when  partially  hard  may  be  followed  with 
very  soft  plaster  in  a  rimless  tray,  with  no  attempt  to  carry  the  plaster  beyond  the 
occlusal  surfaces  of  the  teeth.  In  either  method,  great  care  should  be  employed 
not  to  raise  the  nasal  section,  as  a  slight  pressure  from  below  might  easily  raise  it 
from  its  seating  upon  the  floor  of  the  nares  without  detection,  and  thus  destroy  the 
grasping  fit  of  the  obturator.  In  the  removal  of  the  lingual  portion,  it  should 
separate  freely  and  cleanly  from  the  nasal  portion,  and  then  the  nasal  piece  is  slow- 


CHAPTER  III.     TECHNIC  CONSTRUCTION  OF   VELUM-OBTURATOR  443 

ly  and  carefully  teased  back  with  a  pointed  instrument  and  protected  from  dropping 
into  the  throat  with  a  mouth-mirror.  It  is  quite  important  that  the  exposed  sur- 
face of  the  nasal  section  between  the  cleft  be  thoroughly  lubricated  to  facilitate  its 

separatinc^  easily  from  the  lingual  portion. 

Fig.  11. 


A  simple  two-section  impression. 


With  quite  an  extensive  experience  with  clefts  of  the  character  described 
above,  which  have  been  found  "favorable"  in  diagnosis,  the  author  has  yet  to 
experience  a  single  instance  where  the  nasal  section  with  the  usual  precautions  could 
not  be  taken  in  one  piece  and  easily  removed  without  severe  pain  or  injury.    This 


Fig.  r. 


A  complicated  two-section  impression. 


no  doubt  is  due  to  the  yielding  nasal  tissues.     Fig.  11  shows  different  views  of  a 
two-section  impression  of  a  symmetrical  cleft,  taken  as  described. 

Fig.  12  shows  a  two-section  impression  where  the  thin  ear-like  extension  on 
the  right  side  of  the  nasal  section  shows  how  the  plaster  had  been  forced  into  the 


444 


PART   IX.     rilF.    PROSTHETIC  CORRECTION  OF  CLEFT   PALATE 


A  three-section  impressiun. 


mil  Idle  meatus.   The  impression  illustrates  the  possibility  of  removing  an  extensive 

and  apparently  impossible  nasal  section  in  one  piece.    The  impression  was  removed 

without  a  break,  notwithstanding  the  fact  that  one  of  the  extensions  was  only  a 

little  thicker  than  a  blotter.     This  nicely  illustrates  the  yielding  and  releasing 

possibilities  of  the  nasal  organs,  on  the  same  principle  that  an  impression  of  an  ear 

can  be  easily  removed,  which  would  be  impossible  if  its  framework  was  composed 

of  unyielding  bone. 

Three-Section  Impressions 

F'"^-  '•^-  If  the  lateral  borders  at  the  posterior  en- 

trance to  the  nares  from  the  naso-pharynx 
are  contracted  so  that  the  width  of  the  nasal 
chamber  is  wider  than  its  posterior  entrance, 
or  if  there  are  deep  lateral  sulci  or  attachments 
of  any  character  that  would  prevent  the  direct 
backward  movement  of  the  one  piece  nasal 
section,  the  impression  of  the  nares  should 
be  taken  in  two  sections,  making  a  three- 
section  impression.  Fig.  13  is  made  from 
an  impression  taken  in  this  way,  as  will  be 
described  later. 

With  more  extensive  clefts  entirely  separating  the  hard  palate,  or  which 
extend  diagonally  forward  to  the  right  or  left,  or  upon  both  sides,  along  the  line 
which  would  have  been  the  intermaxillary  suture,  or  as  in  Fig.  14  where  the  whole 
intermaxillary  process  has  been  removed  leaving  a  wide  cleft  in  front,  the  obturator 
should  not  extend  forward  of  a  point  that  is  about  even  with  the  lingual  border 
of  the  alveolar  ridge.  Therefore,  this  part  of  the  cleft  which  is  not  needed  for  the 
working-model,  should  be  filled  with  dough  (made  by  mixing  flour,  powdered 
soapstone,  and  water)  so  that  the  plaster  cannot  dovetail  into  this  section.  See 
Fig.  15.  In  a  case  similar  to  that  shown,  the  space  occupied  by  the  dough  should 
be  filled  finally  with  a  hard-rubber  piece  attached  to  a  removable  restoring  bridge. 
The  restoring  piece  is  made  from  an  impression  taken  after  the  obturator  is  finished 
and  in  the  mouth.  The  object  of  the  denture  is  to  completely  close  the  anterior 
portion  of  the  cleft,  restore  the  normal  lines  of  the  lingual  speaking  arch  and  the 
contour  of  the  upper  lip,  and  permit  free  nasal  breathing.  See  Figs.  40  and  41. 

Occasionally,  the  vomer  will  be  attached  to  the  hard  palate  on  one  side  or 
the  other  of  the  cleft,  presenting  a  hard  smooth  wall  which  extends  upward  and 
toward  the  median  line.  At  times  this  will  involve  the  whole  of  one  side,  preventing 
the  advantage  upon  that  side  for  a  grasp  of  the  obturator  upon  the  floor  of  the  nares. 
At  other  times  only  a  portion  will  be  closed,  leaving  a  roundish  opening  at  its 
anterior  border  extending  on  to  the  floor  of  the  nares.  It  is  usually  desirable  to 
take  advantage  of  this  opening  to  a  moderate  degree,  to  aid  in  sustaining  the  obtura- 
tor upon  that  side,  but  never  to  the  extent  of  preventing  its  easy  removal.     If 


CHAPTER  III.     TECHNIC  CONSTRUCTION  OF   VELUM-OBTURATOR 


445 


the  impression-plaster  is  allowed  to  freely  enter  this  opening,  it  might  cause  trouble. 
It  should,  therefore,  be  prepared  by  stuffing  it  with  dough,  leaving  a  free  border, 
but  with  a  depression  of  sufficient  depth  for  a  slight  rim  of  the  plaster  and  the 
final  obturator  to  fit  into. 

It  should  be  understood  by  this  that  it  is  not  absolutely  necessary  to  obtain 
a  clinging  nasal  seating  for  the  obturator  on  both  sides  of  the  cleft,  and  especially 
not,  if  one  side  has  a  broad  seating,  as  the  veil  of  the  obturator  which  rests  upon  the 
velirm-palati  on  the  other  side  where  it  merges  into  the  hard  palate,  will  pre\'ent 


Fig.  14. 


Fig.  15. 


The  above  is  a  representation  of  a  large  double  cleft.     On  the  right  is  shown  the  position  of  dough  to  prevent 
the  nasal  portion  of  the  impression  from  dovetailing. 

it  from  tipping  or  falling.  An  obturator  of  this  character,  shown  on  the  left  of  the 
upper  group  in  Fig.  39,  is  worn  with  perfect  unconsciousness  of  its  presence,  though 
it  is  not  sustained  by  a  supporting  plate.  Notwithstanding  the  fact  that  this 
patient  was  over  thirty-five  years  of  age  when  the  obturator  was  first  inserted,  she 
has  been  one  of  our  best  patients  at  clinics,  where  she  has  kindly  appeared  to  show 
how  a  cleft  palate  patient  can  be  made  to  speak  perfectly  at  quite  an  advanced 
age,  if  he  has  ambition  and  perseverance. 

Technics  of  Three-Section  Impressions 

With  all  impressions  of  clefts  which  demand  that  the  nasal  portion  should 
be  taken  in  two  sections  the  plaster  is  managed  and  introduced  the  same  as  for  the 
first  half  of  a  single  section,  pressing  it  back  along  the  floor  of  the  nares  upon  one 
side  as  before,  but  stopping  it  at  the  border  of  the  cleft  by  slightly  slanting  the 
exposed  surface  "a,"  Fig.  16,  upward  toward  the  median  line.  Finish  this  first  half- 
section  by  removing  all  portions  of  plaster  adhering  to  the  palatal  surface  and  also 
the  thin  friable  edges  which  have  lapped  on  to  the  palatal  border  "b,"  leaving  a 
narrow  flange  "c"  to  fit  the  palatal  section  when  introduced.    The  mesio-nasal  end 


44() 


PART   IX.     THE  PROSTHETIC  CORRECTION   OF  CLEFT  PALATE 


"d"  of  this  section  is  then  covered  with  a  perfect  separator,  and  the  second  section 
"e,"  Fig.  17,  for  the  opposite  side  is  introduced  and  finished  much  in  the  same  man- 
ner. This  will  leave  a  wide  space  "f"  between  the  two  sections,  which  touch  only 
at  their  mesio-nasal  ends  "d,"  where  they  are  intended  to  unite  to  complete  the 
impression  of  the  floor  of  the  nares.  Any  lateral  branching  of  the  cleft  that  would 
be  liable  to  dovetail  the  plaster,  should  first  be  corrected  with  dough  "g."  It  is 
very  important  that  all  of  the  sections  should  easily  separate  from  each  other  at  the 


Fig.  10. 


Fig.  17. 


Fig.  is. 


The  above  on  the  left,  shows  the  first  plaster  nasal  section  in  place,  in  a  three-section  impression.     On  the  right, 
both  sections  in  place,  and  below  a  transverse  of  the  three  sections:  a,  e,  i,  and  the  dough,  h. 

time  of  removal,  because  so  little  force  can  be  exerted  without  causing  considerable 
pain  to  the  patient.  There  is  always  the  chance  that  they  will  cling  together  so 
firmly  that  the  objects  and  advantages  of  sectional  parts  will  be  lost.  For  this 
reason,  when  the  first  and  second  sections  join  at  "d,"  the  joint  should  be  no  larger 
than  necessary  to  complete  the  impression  at  this  point  upon  the  nasal  floor. 
Again,  the  surfaces  of  the  plaster  that  are  to  join  the  section  to  follow,  should  be 
smoothed  with  the  spatula  in  its  final  finishing.  The  author  has  found  no  lubricant 
more  perfect  at  this  time  than  Brophy's  Separatine,  followed  with  a  solution  of 
soap,  carefully  painted  over  the  surface  with  a  soft  brush. 

The  inverted  V-shaped  space   "f"   between  these  sections  is  then  partially 
filled  with  dough  "h,"  shown  in  the  transverse  section,  Fig.  18,  leaving  a  well  de- 


CHAPTER  III.     TECHNIC  CONSTRUCTION  OF  VELUM-OBTURATOR  447 

fined  edge  "c"  along  the  border  which  is  intended  to  join  the  third  section  "i" 
with  a  clean  cut  fitting  when  the  sections  are  finally  removed  and  joined  outside 
of  the  mouth. 

The  object  of  the  dough  here  is  to  prevent  the  plaster  of  the  third  section 
"i"  from  extending  too  high  upon  the  diagonal  walls  of  "a"  and  "e"  or  over  their 
tops  and  debar  its  easy  removal.  Still,  this  part  of  the  impression  should  be  per- 
fectly marked  with  well  defined  edges  at  "c"  so  there  will  be  no  doubt  of  perfect 
readjustment  of  the  pieces.  Therefore,  before  starting  to  take  the  third  section, 
the  exposed  surfaces  of  the  first  two  should  be  quite  perfectly  smoothed,  while  soft, 
and  thoroughly  lubricated.  The  time  recjuired  for  these  lengthy  necessary  instruc- 
tions should  not  lead  one  to  imagine  that  he  has  time  to  throw  away  at  this  partic- 
ular stage  of  the  operation,  because  at  any  moment  an  irresistible  contraction  of 
the  palatal  or  pharyngeal  muscles  will  be  very  liable  to  draw  the  posterior  ends 
of  the  sections  together,  dislodging  them  from  their  seating  before  the  palatal  sec- 
tion can  be  placed  to  secure  them.  This  has  often  led  the  author  to  omit  the  dough 
for  very  sensitive  patients,  using  special  care  in  placing  the  plaster  with  the  spatula 
for  the  palatal  section  so  as  to  span  the  space.  After  the  removal  of  section  "i" 
and  the  dough  "h,"  Fig.  18,  the  posterior  part  of  the  nasal  sections  is  slightly  drawn 
back  and  forth  toward  the  center  with  a  teasing  movement  to  loosen  it  from  its 
seating.  It  is  then  teased  backward  and  out,  allowing  it  to  take  its  easiest  path. 
The  opposite  section  is  removed  in  the  same  manner.  When  the  three  sections 
are  united,  they  should  give  a  perfect  impression  of  all  that  is  required,  and  with- 
out great  difficulty  in  removal. 

The  one  thing  of  the  greatest  importance,  and  the  one  which  demands  the 
greatest  care  and  delicacy  of  movement  in  taking  these  sectional  impressions,  is  to 
avoid  changing  in  the  slightest  degree  the  seating  of  the  nasal  sections  during  the 
processes  of  the  successive  work,  and  thus  disturb  their  true  final  relations  to  each 
other.  If  the  soft  plaster  in  its  introduction  is  allowed  to  float  back  upon  a  sen- 
sitive soft  palate,  or  a  particle  drops  on  the  back  of  the  tongue  or  in  the  throat, 
it  is  very  liable  to  start  contractions  of  the  muscles  which  will  lift  one  or  both 
of  the  nasal  sections  from  their  attachment  to  the  mucous  membrane.  If  this 
occurs  before  the  final  lingual  section  is  placed,  one  might  as  well  stop  and  begin 
again — but  without  discouragement,  because  of  the  advantage  that  is  always  de- 
rived from  the  experience,  to  both  patient  and  operator. 

Again,  in  clearing  off  the  plaster  that  has  overlapped  the  borders  of  the  cleft, 
and  in  smoothing  and  shaping  the  exposed  surfaces  preparatory  to  introducing  the 
last  section,  or  in  placing  the  dough  between  the  sections,  and  even  in  lubricating 
the  surfaces,  and  finally  the  introduction  of  the  section  with  the  spatula  until  the 
dome  of  the  arch  is  filled  to  the  occluding  surfaces  of  the  teeth,  all  of  this  should 
be  performed  deftly  and  rapidly  with  the  one  idea  in  view  that  the  nasal  sections 
must  not  be  lifted  from  their  seating,  or  their  positions  disturbed  in  the  slightest  degree; 
otherwise,  the  exact  relations  of  the  lingual  and  nasal  surfaces  of  the  working- 


448  PART   IX.     THE  PROSTHETIC  CORRECTION   OF  CLEFT  PALATE 

niock'l  will  be  dcstnjycd,  and  tu  an  extent  that  will  destroy  the  true  working  possibil- 
ities of  the  obturator. 

The  greatest  danger  to  this  special  distortion  of  the  model  lies  in  the  fact 
that  it  is  not  detected  at  the  time,  or  perhaps  not  until  the  obturator  is  found  to  be 
too  loose,  because  its  upper  and  lower  wings  do  not  have  that  close  grasp  upon  the 
hard  palate  that  they  should.  There  should  never  be  any  hesitation  in  taking  another 
impression  to  correct  an  imperfection,  or  when  there  is  a  possibility  of  improving 
a  desired  extent  of  the  impression  of  the  nasal  floor,  or  even  to  correct  it  if  there  is 
any  doubt  as  to  its  perfection.  It  is  rare  for  the  author  to  be  satisfied  with  less  than 
three  impressions,  even  when  the  first  one  seems  to  be  quite  perfect.  This  gives 
an  opportunity  to  compare  results  and  choose  the  best  one.  Operators  of  less 
experience,  therefore,  should  never  hesitate  to  try  many  times  if  not  fully  satisfied; 
though  it  may  be  well  to  postpone  the  operation  to  another  day  to  prevent  undue 
irritation  or  tetanic  contraction  of  the  throat  muscles. 

The  Plaster  Working-Model  of  the  Cleft 

Great  care  should  be  exercised  in  adjusting  the  several  sections  of  the  im- 
pression together,  preparatory  to  filling  for  the  plaster  working-model  (Figs.  19 
and  20),  as  the  slightest  particle  of  plaster  or  debris  between  the  joints  at  this  time 
will  detract  from  the  fit  of  the  obturator.  When  the  sections  are  fastened  firmly 
together  with  wax  at  points  which  do  not  encroach  upon  the  impression,  cover  with  a 
thin  coat  of  brown  shellac  for  demarcation.  When  dry,  follow  with  a  coat  of  sandarac 
vamish,  and  when  this  is  dry,  soak  the  impression  thoroughly  in  water  just  before 
filling.  As  soon  as  the  plaster  is  hard,  commence  separating,  which  will  be  facilitated 
by  occasional  dippings  in  water.  Another  way  is  to  thoroughly  coat  with  Brophy's 
Separatine  following  the  sandarac,  and  follow  this  by  soaking  in  soapy  water. 

Preparatory  to  filling  the  impression,  it  will  be  well  to  remember  what  has  been 
said  of  the  lingual  and  nasal  extensions  of  the  obturator,  and  it  will  then  be  seen 
that  the  only  duplicate  surfaces  of  the  model  desired  from  the  impression  are: 
the  cleft,  and  all  that  portion  of  the  nasal  floor  obtainable,  and  the  required  lingual 
surfaces.  Therefore,  unnecessary  excess  of  plaster  in  filling,  and  consequently  a 
deal  of  work  in  separating  and  trimming  may  be  avoided. 

While  the  plaster  model  should  be  at  first  of  sufficient  body  in  front  to  avoid 
breaking  its  lateral  halves  apart  in  the  process  of  constructing  and  fitting  the 
modeling-compound  model  of  the  obturator,  it  should  be  remembered  also  that  it 
must  be  trimmed  down  ultimately  so  as  to  occupy  only  about  one-quarter  the 
surface  contents  of  the  cleft  palate  flask  in  which  the  obturator  should  take  a 
central  position.  These  details  are  given  because  dentists  who  are  in  the  habit 
of  filling  impressions  for  "models"  for  dentures,  etc.,  may  feel  it  necessary  to  cover 
the  entire  surface  of  the  impression,  and  build  it  over  the  top. 

In  the  selection  of  plaster,  employ  the  kind  that  will  give  a  hard,  smooth, 
strong  model.  To  avoid  air  bubbles,  pour  off  the  surplus  water  from  the  bowl  at  the 


CHAPTER  III.    TECHNIC  CONSTRUCTION  OF   VELUM-OBTURATOR 


449 


moment  the  last  particles  of  plaster  are  sinking  beneath  the  surface.  After  ciuickly 
mixing,  the  remaining  air  bubbles  are  removed  by  a  rotary  movement  of  the  bowl, 
causing  plaster  to  float  upon  the  sides  of  the  bowl,  and  by  occasionally  jogging  it 
upon  the  bench.  This  procedure  should  be  followed  in  pouring  all  the  plaster  and 
investment  models  in  the  flask.  Hold  the  impression  in  one  hand  and  pour  the 
plaster  from  the  bowl  held  in  the  other,  commencing  in  front,  and  causing  it  to 
flow  back  on  each  side  of  the  cleft,  shaking  it  into  another  bowl.  Repeat  this  several 
times,  until  the  required  surfaces  are  covered.  Then  with  the  spatula,  build  it  to 
the  desired  thickness,  height,  and  width.  This  should  leave  the  upper  part  of  the 
nasal  and  posterior  portions  uncovered. 


Fig.  19. 


Fig.  20. 


The  lingual  and  nasal  aspect  of  plaster  working-model  A. 


Figs.  19  and  20  represent  respectively,  lingual  and  nasal  views  of  a  plaster 
model  of  a  typical  cleft  similar  to  that  shown  in  Fig.  1.  In  trimming  the  model,  the 
surfaces  "a"  and  "b" — lingual  and  nasal  aspects — should  be  trimmed  parallel  to 
the  occlusal  plane.  The  distance  between  these  two  surfaces  will  make  the  body  of 
the  model  about  one-half  to  three-fourths  of  an  inch  thick;  though  when  fitted  to 
the  flask,  it  will  be  much  thinner.  Preserve  the  model  of  the  nasal  floor  to  its  outer 
borders  "e"  and  the  lingual  surface  "f"  to  about  one-quarter  of  an  inch  beyond 
that  required  for  the  palatal  or  lingual  extensions  of  the  obturator,  shown  by  the ' 
dotted  lines.  Trim  the  posterior  ends  "c"  "c"  of  the  model  diagonally,  as  shown, 
for  the  final  drawing  surfaces  of  the  casts.  If  the  posterior  borders  of  the  model 
of  the  cleft  at  "d"  are  drawn  toward  each  other,  as  they  usually  are,  making  the 
cleft  narrower  at  that  point,  trim  them  parallel  so  that  the  trial-model  will  readily 
slip  back  and  out  of  the  model  of  the  cleft  during  its  forming  and  fitting.  It  will  be 
shown  later  how  these  are  restored  on  the  model  so  that  the  obturator  will  allow 
full  play  of  the  velum-palati  in  swallowing,  etc. 


CHAPTER  IV 


THE  TRIAL-AIODEL  OF  THE   OBTURATOR 

The  surface  of  the  plaster  model  being  rubbed  with  fine  soapstone,  select 
a  piece  of  tough  modeling-compound  and  form  it  into  a  solid  ball  about  the  size  of  a 
hickory  nut,  and  press  it  into  the  cleft  of  the  model  and  spread  it  out  above  and 
below  to  about  the  thickness  of  a  rubber  plate  over  the  lingual  and  nasal  surfaces. 
Remove  it  from  the  cleft  while  it  is  partially  soft  and  trim  off  excess  with  scissors. 
Then  replace  and  dip  the  whole  into  warm  water,  and  continue  the  forming  and 
trimming  of  the  body  of  the  trial-model  in  this  way  until  ready  to  try  in  the  mouth. 

Figs.  21  and  22  represent  respectively,  the  lingual  and  nasal  views  showing 
the  partially  formed  trial-model  in  position.  The  oral  portion  of  the  trial-model, 
shown  in  Fig.  21,  should  usually  extend  over  the  roof  of  the  mouth  no  further  than 
about  three-eighths  of  an  inch  from  the  borders  of  the  cleft,  be  the  cleft  large  or 

Fig.  22. 


small,  its  posterior  borders  should  stop  well  in  front  of  the  attachments  of  the  velum- 
palati.  This  will  leave  a  narrow  space  "g"  on  the  plaster-model,  to  be  finally  con- 
caved for  the  seating  of  the  central  or  palatal  plaster  and  metal  casts.  The  anterior 
and  lateral  nasal  extensions  "h,"  Fig.  22,  may  be  very  much  abridged  as  shown,  for 
the  early  trials.  This  will  enable  a  much  easier  adjustment  in  the  fitting  process  to 
carry  the  trial-model  back  into  the  throat  before  lifting  it,  to  bring  it  forward  to  its 
seating  in  the  cleft.  This  is  especially  important  in  the  trial  fitting  of  the  veil. 
The  central  portion  "i"  between  the  cleft,  which  in  the  final  preparation  is  mainly 
cut  away,  should  be  left  for  strength  during  the  trial  movements,  it  being  curved 
forward,  as  shown,  to  obtain  a  clear  view  of  the  pharyngeal  wall  and  muscles  during 
the  fitting  of  the  veil.  * 

450 


CHAPTER   IV.     THE   TRIAL-MODEL  OF   THE  OBTURATOR 


451 


A  strong  silk  ligature  "k,"  Fig.  21,  is  usually  attached  to  facilitate  the  intro- 
duction and  removals  of  the  trial-model,  and  to  recover  it  from  the  grasp  of  the 
throat  muscles,  in  case  of  its  accidental  falling.  With  one  or  more  fingers  resting 
on  the  under  surface  of  the  trial-model,  and  with  the  ligature  held  tautly  with  the 
other  fingers,  a  sufficiently  firm  hold  may  be  obtained  to  carry  it  back  in  the  mouth 
until  the  lateral  nasal  extensions  "h,"  Fig.  22,  will  allow  it  to  be  carried  far  back,  up 
and  forward  to  place.  Another  very  important  object  of  the  ligature  is  that  the 
trial-model  can  be  held  safely  forward  in  position  by  passing  the  ligature  between 
two  of  the  teeth  with  a  knot  in  front.  This  will  allow  the  patient  to  close  the  mouth 
and  take  time  to  become  somewhat  accustomed  to  it,  and  he  will  be  able  to  note 
if  there  are  any  points  of  irritation  in  swallowing,  etc.  These  rests  with  the  trial- 
model  in  place  are  of  the  greatest  advantage  later  in  the  forming  and  fitting  of 
the  veil.  This  is  the  time  to  observe  if  the  fit  is  perfect  and  if  it  will  securely  retain 
its  position  when  the  nasal  wings  are  extended. 

To  the  posterior  borders  of  the  trial  or  obturator  model,  where  the  lateral 
wings  of  the  lingual  portions  curve  over  the  l)orders  of  the  cleft  "d,"  Fig.  21,  to  join 
the  nasal  portions,  the  surfaces  must  permit  the  free  action  of  the  muscles  in  swal- 
lowing, etc.  This  can  be  determined  with  the  trial-model  in  the  mouth.  Occasion- 
ally, the  attachment  of  the  palatal  muscles  is  so  far  forward  along  the  edges  of  the 
osseous  cleft,  it  will  be  found  necessary  to  scrape  the  inner  surfaces  of  the  model 
which  will  leave  a  space  shown  at  "d"  between  the  borders  of  the  plaster  and  trial- 
model  at  this  point,  especially  if  the  plaster-model  has  been  trimmed  off  to  parallel 
the  edges.  Later,  upon  completion  of  the  final  model  of  the  obturator,  these  spaces 
must  be  closed.  This  procedure  is  described  in  Chapter  V. 

The  Veil  of  the  Obturator. — When  satisfied  with 
the  form  and  fit  of  the  body  of  the  trial-model,  show- 
ing that  another  impression  will  not  be  necessary  to 
secure  perfect  coaptation  to  the  hard  surfaces  for  this 
portion  of  the  obturator — the  next  move  is  to  arrange 
for  a  wire  loop  guide  for  forming  and  fitting  the  veil 
of  the  obturator. 


Fig.  23. 


Constructing  the  Veil  of  the  Obturator 
Fig.  23  is  a  nasal  view  of  the  plaster-model  with 
the  partially  formed  trial-model  in  place,  showing 
short  pieces  of  tubing  "m"  (No.  23  nickel-silver 
rotating  tube)  imbedded  in  the  compound,  with  a 
copper  wire  "n"  in  position,  the  loop  being  bent 
to  conform  somewhat  to  the  size  and  form  of  the 
pharyngeal  walls.  This  is  for  the  purpose  of  exactly  gauging  the  extent  and  position 
of  the  veil  of  the  obturator  by  a  visual  observation  of  the  pharyngeal  walls  above 
and  below  the  loop,  during  a  physiologic  action  of  the  muscles.   This  enables  one 


452  PART   IX.     THE  PROSTHETIC  CORRECTION  OF  CLEFT   I'M. ATE 

to  form  and  place  the  wire  and  ultimate  border  of  the  veil  exactly  alonj^  the  lines 
of  physiologic  demands,  thus  freeing  this  most  important  part  of  the  whole  opera- 
tion from  the  "guesswork"  of  former  methods  which  have  always  debarred,  the 
scientific  advancement  of  the  prosthetic  correction  of  this  deformity. 

In  the  first  trials,  force  the  loop  well  into  the  tubes  to  insure  against  having  it 
too  large,  and  to  accustom  the  patient  to  its  introduction.  It  can  then  be  enlarged, 
and  shaped  to  conform  to  the  pharyngeal  walls  during  the  contraction  of  the 
zone  which  is  to  determine  the  outline  of  the  borders  of  the  final  veil. 

In  the  preliminary  and  present  study  of  the  pharynx,  one  should  note  first, 
the  position  of  the  greatest  forward  extension  of  the  superior  pharyngeal  muscle. 
This  can  easily  be  ascertained  by  titillating  the  throat  tissues  to  the  point  that 
starts  the  act  of  gagging.  By  watching  at  that  moment  the  otherwise  smooth 
posterior  pharyngeal  wall,  a  transverse  fold  will  be  seen  to  stand  forward  along  the 
zone  where  the  velum-palati  rests  in  closing  the  oro-nasal  passage.  This  is  the 
superior  pharyngeal  muscle  in  its  somewhat  abortive  effort  to  imitate  its  more 
normal  action.  Its  position  is  usually  below  the  line  of  direction  of  the  hard  palate, 
and  usually  below  the  orifices  of  the  Eustachian  tubes.  With  cleft  palate  patients 
it  is  rarely  developed  as  in  normal  conditions,  or  as  it  will  be  later  (if  the  patient  is 
not  too  old)  under  the  stimulation  induced  in  co-operating  with  the  artificial  veil, 
in  performing  the  important  function  of  closing  the  oro-nasal  passage,  which  is  its 
main  function  under  normal  conditions  in  the  activities  of  speech. 

The  position  of  this  muscle  will  be  a  guide  to  the  height  and  line  of  the  loop  at 
that  point,  as  the  lower  edge  of  the  border  of  the  veil  should  be  an  eighth  of  an 
inch  or  more  above  the  line  of  the  greatest  extension  of  this  muscle  and  it  should 
no  more  than  barely  touch  the  veil.  The  subsequent  development  of  this  and  other 
pharyngeal  muscles  will  complete  the  necessary  occlusion.  Fig.  24  will  give  some- 
thing of  an  idea  of  the  relation  of  the  veil  to  the  superior  pharyngeal  muscle,  but  it 
should  not  be  regarded  as  an  invariable  guide  to  modern  treatment,  as  it  will 
frequently  be  advisable  to  raise  the  posterior  border  of  the  veil  above  the  relative 
position  shown  in  this  picture.  It  will  be  found  necessary  to  frequently  induce  a 
contraction  of  the  throat  muscles  by  titillating  the  soft  palate,  or  by  asking  the 
patient  to  partially  swallow  with  the  mouth  open.  If  the  loop  of  wire  touches  or 
presses  upon  the  contracted  pharyngeal  muscles  at  any  point,  it  should  be  bent 
away,  or  perhaps  forced  farther  into  the  tubes.  At  the  posterior  lateral  angles  of 
the  pharynx,  and  above  the  line  of  the  veil,  the  entrances  to  the  Eustachian  tubes 
should  be  seen.  These  should  never  be  covered,  or  encroached  upon  by  the  borders 
of  the  veil.  Below  these  openings  the  walls  are  frequently  thrown  into  perpendicular 
folds,  which  if  prominent,  as  they  occasionally  are,  and  the  desired  zone  during 
contraction  of  the  muscles  is  not  smooth,  it  may  be  necessary  to  slightly  raise  or 
lower  the  angle  of  the  veil  at  that  point  to  a  smoother  zone,  or  to  more  closely 
fit  it  to  the  irregularities  to  assure  the  probability  of  a  complete  closure  of  the  oro- 
nasal  passage. 


CHAPTER  IV.     THE  TRIAL-MODEL  OF   THE  OBTURATOR 


453 


However,  there  can  be  no  cut  and  dried  rules  in  regard  to  the  exact  position 
of  the  veil  in  relation  to  the  superior  pharyngeal  muscle,  except  that  it  should  rest 
in  such  a  position  in  the  relaxed  state  of  the  muscles,  that  the  palatal  muscles 
in  swallowing,  will  raise  it  above  the  greatest  contractility  of  all  the  pharyngeal 
muscles,  so  that  they  cannot  get  it  within  their  grasp  to  cause  its  downward  move- 

FiG.  24. 


ment.  In  one  instance  it  was  necessary  to  place  the  posterior  border  three-eighths 
of  an  inch  above  the  superior  pharyngeal  to  obtain  the  most  practical  use  of  the 
obturator. 

A  roll  of  modeling-compound  a  trifle  larger  than  one-half  the  diameter  of  a 
pencil,  and  of  sufficient  length  to  more  than  reach  around  the  loop,  is  now  warmed 
at  one  end  over  a  small  jet  of  a  Bunsen  Burner,  with  sufficient  heat  to  enable  its 
firm  cohesion  to  the  trial-niodel  at  the  point  "n,"  Figs.  23  and  25,  where  the  loop 
emerges  from  the  tube.  Then  with  slight  warmings,  carry  it  around  the  loop  im- 
bedding it  in  its  substance  to  the  other  end;  finally,  cut  off  the  surplus  and  attach 
the  end  as  before.  This  is  shaped  by  the  fingers,  so  as  to  leave  the  outer  border 
rounded  and  the  inner  ("o")  pinched  to  a  V-edge  to  evenly  join  the  line  of  the  final 
thin  central  portion  of  the  veil. 

A  proper  degree  of  judgment  based  upon  the  position  and  action  of  the  muscles 
and  their  reqmrements  in  speaking,  will  enable  this  preliminary  shaping  of  the  loop 
and  border  of  the  veil  to  its  relations  with  the  pharyngeal  walls.  When  in  place, 
it  can  easily  be  seen  where  the  contracted  muscles  press  too  hard  upon  it,  even 
though  the  patient  may  not  complain  of  irritation  in  swallowing;  these  places 


454 


PART   IX.     Tim  PROSTHETIC  CORRECTION   OF  CLEFT  PALATE 


Fig.  25. 


should  l)c  Irimmc'd.  or  warmed  rind  ])rcssed  back,  and  their  positions  confirmed  by 
repeated  trials. 

Cireat  care  must  always  be  exercised  in  the  repeated  necessary  introduction  and 
removal  of  the  model,  to  prevent  changing  its  form.  This  danger  debars  soften- 
ing the  border  of  the  model  sufficiently  to  obtain  an  exact  impression  of  the  muscles 

in  their  contracted  state  along  the  desired  zone, 
though  a  jet  of  warm  air  or  water  upon  limited 
areas  followed  with  repeated  acts  of  the  patient's 
swallowing,  might  accomplish  this. 

As  the  speaking  efficiency  of  the  obturator  de- 
pends so  largely  upon  the  form  and  relative  posi- 
tion of  the  veil,  it  should  be  regarded  as  the  most 
scientific  part  of  the  whole  operation,  and  propor- 
tionate care  and  skill  given  to  forming  the  model. 
It  is  C]uite  necessary  to  obtain  a  close  coapta- 
tion of  the  anterior  lateral  borders  of  the  veil 
("r,"  Fig.  25),  in  relation  to  the  contracted  walls 
of  the  naso-pharynx,  especially  when  there  is  little 
or  no  activity  of  the  lateral  pharyngeal  muscles. 
This  is  to  prevent  the  escape  of  air  into  the  nose 
at  these  points.  For  this  reason  one  should  strive 
to  extend  the  plaster  impression  to  these  surfaces 
far  enough  at  least  to  obtain  the  lines  of  direction  for  correctly  molding  this  portion 
of  the  veil,  being  careful  also  that  the  surfaces  are  not  extended  so  far  as  to  pro- 
duce irritation. 

Remember  that  the  line  of  the  posterior  peripheral  surface  "s,"  Fig.  25,  of 
the  entire  border  of  the  veil  should  follow  the  contour  lines  of  the  muscles  along  the 
pathway  of  the  chosen  zone  at  the  moment  of  their  greatest  contraction,  and  should 
never  be  allowed  to  more  than  barely  touch  at  any  point.  Later,  after  the  first 
obturator  is  vulcanized  and  worn  for  a  few  days,  if  it  is  found  needful  to  extend  the 
border  at  any  place  to  aid  the  patient  to  more  completely  close  the  oro-nasal  pas- 
sage, it  can  easily  be  accomplished  by  scraping  the  metal  casts,  and  if  too  long,  the 
obturator  can  be  reduced.  These  movements  should  be  done  cautiously,  however, 
if  the  obturator-model  has  been  properly  formed,  because  the  subsequent  functional 
efforts  of  the  muscles  to  completely  close  an  almost  closed  opening  in  uttering  all 
of  the  oral  elements,  except  m,  n,  and  ng,  will  cause  these  muscles  which  have  never 
been  used  under  speech  impulses,  to  develop  surprisingly.  To  leave  the  largest 
possible  space  at  the  posterior  border  of  the  veil  when  the  muscles  are  relaxed,  is  of  the 
greatest  importance  to  speech  and  healthful  breathing  (Fig.  26). 

This  part  of  the  work  should  not  be  done  hastily,  or  with  lengthened  sittings, 
as  an  irritated  condition  of  the  sensitive  pharyngeal  mucous  membrane  will  start 
a  tetanic  contraction  of  the  muscles  that  will  lead  to  a  very  deceiving  estimation 


Nasal  view  of  the  completed  model  of  the  obturator 
placed  on  the  plaster  working-model. 


CHAPTER   IV.     THE  TRIAL-MODEL  OF   THE  OBTURATOR 


455 


Fig.  2(1. 


of  the  size  of  the  pharynx  in  its  apparently  relaxed  state.  One  will  often  be  sur- 
prised after  a  supposedly  perfect  fitting  of  the  veil,  to  find  on  a  later  day  that  it 
should  be  considerably  extended. 

It  would  be  well  to  state  at  this  time  that  one  is  likely 
to  meet  with  an  unusual  variation  in  the  form  of  the 
pharynx  and  the  position  and  action  or  inaction  of  the 
pharyngeal  mviscles.  This  is  not  easily  discernible,  and 
may  allow  the  obturator  to  unexpectedly  fall  from  its 
safe  position,  even  when  a  perfect  impression  has  been 
secured,  shown  by  the  difficulty  in  removals  of  the  trial- 
model  and  final  obturator.  It  seems  to  occur  during  a 
relaxation  of  the  muscles  in  a  sudden  forcible  intake  of 
the  breath,  and  is  usually  remedied  by  tipping  the  veil 
of  the  obturator  up  to  a  higher  position  in  the  pharynx. 
Only  in  one  instance,  in  the  author's  practice,  has  this 
resulted  in  danger  of  swallowing  the  obturator.  It  oc- 
curred with  a  woman  about  forty  years  of  age,  whose 
Designed  to  show  the  trial-model  of  the  obturator  was  scemlugly  perfect  and  worn  at  all  hours 
•  portiOT°opra.''°a^nd°thr'usuli'dSanc^e  during  scvcral  wecks  of  speech  training.  About  two  weeks 

between   the  posterior  borders  of  the  i  i  ■  i  1    -1 

veil  and  the  phar^'ngeai  walls  when  the  after  slic  rctunied  to  hcr  somcwhat  distant  home,  while 

muscles  are  completely  relaxed. 

talking  and  laughing  with  her  friends,  the  obturator 
dropped  into  her  throat  and  apparently  was  swallowed.  Fortunately  it  produced 
an  almost  immediate  nausea  and  vomiting,  with  its  recovery.  It  was  found  upon 
her  return  to  the  office  several  weeks  later  that  the  attachment  and  action  of  the 
posterior  lateral  muscles  were  very  much  higher  in  the  throat  than  is  common, 
and  in  a  forcible  drawing  in  of  the  breath  with  her  head  thrown  back,  the  obtura- 
tor slipped  backward — which  is  a  common  movement  with  all  obturators — and 
instead  of  the  muscles  forcing  it  back  to  place  as  they  should,  it  dropped  sufficiently 
to  be  partly  swallowed.  By  bending  the  posterior  portion  of  the  veil  upward  so  that 
its  rim  when  in  the  most  posterior  position  rested  above  the  Eustachian  tubes — 
which  in  this  case  were  quite  low — it  was  found  impossible  to  dislodge  it  as  before. 

In  order  to  have  her  feel  perfectly  safe  with  it.  however,  a  very  light  retaining- 
plate  was  made  as  described,  but  with  the  belief  that  it  will  be  abandoned  as  soon 
as  confidence  is  restored. 

If  the  rules  here  given  are  followed  and  a  proper  choice  of  the  palato-pharyngeal 
zone  is  made,  together  with  a  perfect  and  sufficiently  extensive  fitting  upon  the 
nasal  floor,  the  velum-obturator  should  be  worn  with  comfort,  safety,  and  uncon- 
sciousness of  its  presence  in  the  mouth  during  all  waking  and  sleeping  hours, 
and  without  a  supporting  plate  in  most  instances  from  the  very  start.  Patients 
under  twenty  years  of  age  soon  learn  to  speak  with  the  velum-obturator  with  such 
perfect  articulation  and  tone,  that  strangers  do  not  suspect  their  deformity. 


CHAPTER  V 

'IHF,  T.ABORATORY  TECHXIC  CONSTRUCTION  OF  THE  OBTURATOR-AIODEL 

The  remaining  portion  of  the  operation  is  purely  mechanical;  and  while  it 
may  seem  to  be  somewhat  complicated  to  a  novice,  and  really  does  demand  quite  a 
high  degree  of  exactness  in  mechanical  technic,  it  is  after  all  the  same  character 
of  procedure  which  is  familiar  to  skilled  dentists. 

In  preparing  the  modeling-compound  obturator-model  for  investment,  the 
nasal  wings  "h,"  Figs.  22  and  25,  should  now  be  extended  as  shown  by  "r,"  Fig. 
30,  and  then  the  entire  model  should  be  finished  to  no  thicker  at  any  point  than 
a  thin  rubber  plate.  The  part  which  represents  the  inner  border  of  the  veil  "o," 
Fig.  25,  Chapter  IV,  should  be  concaved  on  its  upper  and  lower  surfaces  to  an  even 
knife-blade  edge,  leaving  the  rounded  peripheral  border  "s"  about  H  of  an  inch 
thick.  Great  care  must  be  exercised  that  the  position  and  shape  of  this  important 
peripheral  rim  of  the  velum  is  not  changed  from  its  original  formation  in  the  mouth. 
All  the  central  portion  of  the  obturator-model  within  the  loop,  as  shown  in  Fig.  25, 
is  cut  away  to  more  accurately  determine  the  thickness  of  the  nasal  and  lingual 
walls  of  the  body,  and  the  line  "o."  When  this  is  finished,  cut  a  pattern  from  a  thin 
business  card  by  first  outlining  it  with  a  pencil  along  the  inner  borders  of  the  open 
loop.  This  when  bent  to  the  proper  curve  to  form  the  dome  of  the  arch,  shoidd  be 
waxed  evenly  in  place  along  its  outer  edge  to  form  the  central  portion  of  the  ob- 
turator-model. There  is,  however,  no  objection  to  spanning  this  space  with  a  very 
thin  sheet  of  wax.  The  tubes  at  the  ends  of  the  wire  loop  which  extend  into  the 
body  of  the  trial-model,  if  exposed,  may  be  cut  off  and  removed.  The  rest  of  the 
loop  imbedded  in  the  modeling-compound  border  of  the  veil,  shovdd  be  allowed 
to  remain,  if  possible,  to  strengthen  this  frail  portion  of  the  model  which  has  cost 
so  much  labor  and  skill  to  form. 

If  the  impression  of  the  nasal  floor,  shown  by  the  plaster-model,  is  more  ex- 
tensive than  seems  to  be  necessary  to  support  the  obturator,  the  added  nasal- 
wings  of  the  obturator-model  need  not  extend  to  its  outer  borders  ("r,"  Fig.  30). 
Later,  if  desired,  the  nasal  metal  cast  which  fills  this  space  may  be  cut  back  to  allow 
a  greater  extension. 

It  is  of  the  greatest  importance  that  the  finished  obturator-model  be  reduced 
to  the  minimum  of  thickness  and  heft  to  meet  the  demands  of  strength  and  dur- 
ability of  the  obturator,  being  careful  to  leave  a  sufficiently  wide  and  firm  periph- 
eral rim  at  the  border  of  the  veil,  to  aid  the  pharyngeal  muscles  in  closing  the 
oro-nasal  passage,  not  only  to  aid  in  the  safe  support  and  retention  of  the  obturator, 
but  also  to  increase  its  possibilities  in  the  activities  of  speech.    The  finishing  and 

456 


CHAPTER   V.     LABORATORY   TECHNIC  CONSTRUCTION  457 

smoothing  the  surfaces  of  the  obturator-model  are  best  accompHshed  with  Hght 
sharp  scrapers,  being  always  careful  to  avoid  changing  the  relative  position  of  the 
veil.  It  will  be  remembered  that  its  dimensions  at  any  point  may  at  any  time  be 
increased  by  scraping  the  metal  casts,  and  decreased  by  scraping  the  obturator. 

With  the  finished  obturator-model  in  position  on  the  plaster  working-model, 
restore  with  plaster  as  mentioned  under  Fig.  19  the  posterior  borders  of  the 
cleft  by  filling  the  V-shaped  spaces  "d,"  Fig.  21,  which  represent  the  natural  con- 
tracted position  of  the  border  of  the  cleft  at  the  point  where  the  natural  velum 
joins  the  hard  palate.  These  restorations  can  be  further  finished  on  the  plaster- 
model,  if  edges  are  presented  after  the  final  removal  of  the  obturator-model  from 
its  investment,  as  will  be  described.  Before  filling  these  V-shaped  spaces,  however, 
the  obturator-model  must  be  removed  to  permit  deepening  and  roughening  the 
surfaces  so  that  the  added  plaster  will  perfectly  adhere.  The  above  restoration, 
however,  is  not  always  necessary  with  every  cleft.  One  should  fully  appreciate 
that  this  original  model  of  the  cleft  (Figs.  19  and  20)  represents  the  only  surfaces 
which  the  obturator  is  supposed  to  exactly  fit  the  hard  parts  of  the  mouth  and  nasal 
cavity.  It  should,  therefore,  be  carefully  protected  from  injury  through  the  many 
technic  trials  to  which  it  is  subjected. 

In  preparing  the  plaster  working-model  for  investment  in  the  flask,  the  pos- 
terior ends  "c,"  Fig.  21,  should  extend  no  farther  than  the  requirements  of  the 
lingual  portion  of  the  obturator,  with  surfaces  slanting  slightly  upward  and  for- 
ward. Space  should  be  allowed  at  the  lingual  borders  of  the  obturator  for  a  concave 
seating  "g,"  as  will  be  described  later. 

Fig.  27. 


The  Flask 

Fig.  27  illustrates  the  cleft  palate  flask  closed  with  its  lingual  and  nasal  covers 
(named  according  to  their  relations  to  the  cleft),  and  provided  with  fittings  to  hold 
the  parts  firmly  in  position  during  vulcanizing,  etc.  The  body  of  the  flask  is  beveled 
and  finished  on  the  inside,  as  shown  by  Fig.  28,  which  gives  an  interior  view  of  a 


458  PART   IX.     THE  PROSTHETIC  CORRECTION   OE   CLEET  PALATE 

vertical  antero-posterior  section  throujj;!!  the  Ijody.  'I'he  beveled  planes  divide 
the  contents  of  the  flask  into  lingual  and  nasal  halves,  which  permit  the  separa- 
tion and  removal  of  the  casts  from  the  flask,  and  from  each  other.     The  round 


holes  in  the  sides  of  the  flask  are  for  the  insertion  of  a  screw-driver  to  separate 
the  upper  and  lower  metal  casts  after  they  have  been  poured,  and  also  after  vul- 
canizing. These  should  be  filled  with  investment  to  present  a  smooth  surface  on 
the  inside  of  the  flask,  until  needed. 

Preliminary  Principles 

With  the  model  of  the  obturator  finished  and  on  the  working-model  of  the 
cleft,  the  object  now  is  to  completely  invest  the  obturator-model  in  parts  in  plaster 
which  may  be  easily  removed  from  the  flask,  and  cleanly  separated  from  each  other 
and  the  obturator-model  intact.  It  therefore  must  be  apparent  that  when  these 
plaster  parts  are  duplicated  in  metal  and  the  space  of  the  obturator-model  is 
packed  with  rubber  and  vulcanized,  the  hard  rubber  obturators  can  be  easily 
removed  from  the  metal  casts  ready  for  finishing,  in  the  same  way  that  dentists 
pack,  vulcanize,  and  finish  their  rubber  plates. 

On  the  same  principle  that  dentists  invest  the  trial  plate  of  a  rubber  denture 
in  plaster — one  surface  of  which  is  represented  by  the  model  of  the  mouth — 
and  the  whole  so  arranged  that  when  the  flask  is  opened  and  the  trial  plate  removed, 
the  space  it  occupied  is  packed  with  rubber  and  vulcanized,  so  also,  the  investment 
of  the  plaster-model  made  from  the  impression,  and  the  trial-model  of  the  obturator 
in  a  cleft  palate  flask  is  practically  the  same.  The  only  difference  being:  the 
plaster  surroundings  of  the  trial-model,  in  this  case,  must  be  divided  into  parts 
that  are  formed  so  they  can  be  easily  removed  intact  from  the  flask  and  trial-model, 
because  they  represent  in  connection  with  the  original  working-model  the  models 
that  are  duplicated  in  Babbitt's  metal  for  the  final  vulcanizing  of  the  obturator. 
Of  course,  these  plaster  models  could  be  returned  to  the  fiask,  and  the  space  occupied 
by  the  trial-model  could  be  packed  with  rubber  and  vulcanized  to  form  an  unfinished 
obturator,  the  same  as  dentists  pack  their  rubber  plates,  but  the  models  for  future 
obturators,  which  have  cost  so  much  time  and  skill  to  prepare  would  be  destroyed, 
and  what  is  of  great  importance,  you  would  be  deprived  of  the  opportunity  to 
skillfully  correct  slight  imperfections  in  the  obturators  by  making  required  changes 


CHAPTER    V.    LABORATORY    TECHNIC  CONSTRUCTION  459 

in  the  casts.  This  is  one  of  the  principal  features  of  this  system,  which  pertains 
to  the  entire  life  of  the  patient. 

The  somewhat  intricate  processes  that  are  necessary  in  the  duplication  of 
this  first  set  of  plaster  models  in  metal  which  surround  the  obturator  in  the  flask 
have  always  been  a  great  stumbling  block  to  students,  largely  because  they  do  not 
think  out  for  themselves  the  absolute  need  of  these  movements,  which  have  been 
freed  as  far  as  possible  from  every  complication  during  many  years  of  practice. 
If  they  should  take  one  of  these  plaster  parts  as  a  pattern  to  a  foundry  to  be  du- 
plicated in  metal,  they  would  easily  understand  that  the  molder  would  first  sur- 
round it  with  sand  in  such  a  way  as  to  remove  the  pattern  and  fill  the  space  it  occupied 
with  the  metal.  In  that  case  the  walls  of  the  chamber  after  the  pattern  is  removed 
are  composed  wholly  of  sand  and  are  the  exact  impression  of  the  peripheral  surfaces 
of  the  pattern.  In  our  duplication  of  these  models  or  patterns  in  metal,  the  walls  or 
chambers  of  each  one  are  made  up  of  the  flask  upon  one  side,  and  the  investment 
plaster  models  on  the  other  sides;  and  then  as  each  cast  is  poured,  it  becomes  one  of 
these  parts,  so  that  when  all  of  them  are  poured  they  fit  perfectly  together  in  the 
flask ;  and  being  duplicates  of  the  first  set  of  plaster  models,  they  form  a  chamber 
for  vulcanizing  the  obturator — as  will  be  fully  explained. 

To  many  practitioners  of  dentistry  who  contemplate  undertaking  this  work, 
the  detailed  descriptions  and  repetition  of  words  and  ideas  will  doubtless  seem 
to  be  quite  unnecessary  and  verbose,  but  possibly  excusable  when  they  remember 
that  it  is  written  mainly  for  the  education  and  guidance  of  college  students  by  an 
author  who  has  been  engaged  in  teaching  for  many  years  and  fully  realizes  this 
necessity. 

The  metal  casts  and  the  flask  for  each  individual  case  should  be  regarded 
as  the  valuable  life  property  of  the  patient,  and  if  not  given  into  his  hands  at  the 
close  of  the  operation,  they  should  be  kept  in  a  fire-proof  safe  to  be  turned  over 
to  him  upon  demand,  so  that  if  necessary,  other  dentists  can  renew  the  obturators. 

The  First  Set  of  Plaster  Models 

In  preparing  the  first  set  of  plaster  models  which  are  to  surround  the  obturator- 
model  and  are  ultimately  to  be  duplicated  in  metal,  the  important  feature  is  the 
carrying  into  the  combination,  as  one  of  its  parts,  the  original  plaster  working- 
model  A  (Figs.  19  and  20),  made  from  the  impression  of  the  cleft.  The  plaster 
models  should  be  of  the  strongest  possible  quaHty  of  plaster,  because  from  these 
are  made  the  investment  models  for  making  the  final  metal  casts,  and  are  conse- 
quently subjected  to  conditions  that  tend  to  injure  or  break  them.  The  easy  re- 
moval of  plaster  casts  from  the  flask  is  possible  only  by  keeping  the  inside  surfaces 
of  the  flask  polished  and  oiled. 

As  before  outlined,  in  fitting  the  plaster-model  A  (Figs.  29  and  30)  to  the  flask, 
it  is  placed  in  such  a  position  that  tlie  obturator-model  will  occupy  a  central  posi- 
tion in  the  flask,  leaving  sufficient  room  "g"  between  the  top  of  the  flask  and  the 


460 


FART  IX.     THE  PROSTHETIC  CORRECTION  OF  CLEFT  PALATE 


outer  edges  of  the  lingual  wings  of  the  obturator-model  for  the  seating  of  that  por- 
tion of  the  "palatal"  or  lingual  cast  C,  Fig.  31.  Preliminary  to  fitting  it  into  the 
flask,  therefore,  the  lingual  surface  A,  Fig.  29,  should  be  evenly  trimmed  parallel 
to  the  line  of  the  lingual  wings  and  general  plane  of  the  obturator-model.  Then 
by  outlining  with  a  pencil  the  inner  edge  of  the  flask  upon  the  model,  as  shown  by 
the  dotted  line  in  Fig.  25,  it  can  be  roughly  trimmed,  and  the  space  between  it 
and  the  flask  filled  with  plaster.  The  nasal  surface  of  this  plaster-model  should  be 
beveled  even  with  the  dividing  line  of  the  flask  "b,"  Fig.  30. 


Fig.  29. 


Fig.  30. 


Lingual  Aspect. 


Nasal  Aspect, 


After  fitting  and  securing  with  plaster  the  model  A  in  position,  it  should 
be  removed  from  the  flask  and  finally  trimmed  as  above,  and  then  returned  to 
the  flask  for  making  the  rest  of  the  surrounding  models.  The  plaster  nasal  model 
B,  Fig.  31,  may  be  made  first  as  follows:  With  the  model  A  and  the  obturator- 
model  in  position,  fill  the  rest  of  the  upper  half  of  the  flask  with  dough  to  produce  a 
matrix  to  pour  against.  See  Fig.  30.  Dough  is  easily  and  cjuickly  prepared,  it 
yields  at  the  slightest  touch,  and  will  not,  therefore,  force  the  delicate  rim  of  the 
veil  out  of  position  in  placing  it,  and  yet  it  possesses  sufficient  stability  to  retain 
its  integrity  against  the  introduction  of  the  plaster.  The  dough,  where  it  joins 
the  other  parts,  should  be  smoothed  with  a  wax  spatula  even  with  the  line  of  the  ^^ 
plaster-model  and  along  the  proper  dividing  and  separating  lines  around  the 


CHAPTER    V.     LABORArORY    TECIIXIC  CONSTRUCTIO.X  461 

obturator-model  of  the  veil,  and  the  parting  line  of  the  beveled  planes  of  the  flask. 
Along  the  surfaces  of  the  veil  rim,  "s"  and  "o,"  Fig.  25,  the  dough  should  be  placed 
so  that  the  plaster  cast,  about  to  be  poured,  will  draw,  else  this  delicate  structure 
will  be  broken  in  the  removal  of  the  cast  from  the  flask.  Remember,  that  you  are 
now  preparing  the  natural  parting  lines  of  the  future  metal  casts  from  which  the 
hard  vulcanized  rubber  obtvirator  is  to  be  removed. 

Fig.  30  is  the  nasal  aspect  showing  the  lingual  half  of  the  flask  filled  with  the 
plaster-model  A,  and  the  dough,  with  the  obturator-model  in  position  ready 
for  pouring  the  plaster  nasal  model  B  (see  Figs.  29  and  31).  In  Fig.  30,  the 
central  part  of  the  veil  is  shown  filled  with  dough.  A  later  and  more  preferable 
method  is  to  span  this  loop  with  a  pattern  cut  from  a  thin  card  as  before  described. 
The  exposed  surfaces  of  the  plaster-model  A  should  receive  a  thorough  coat  of 
Brophy's  Separatine,  and  when  dry,  cover  all  the  surfaces  with  thin  soapy  water 
before  pouring  the  plaster.  If  sandarac  varnish  is  used  it  must  not  touch  the 
modeling-compound,  as  it  will  dissolve  its  surface  and  stick  it  to  the  model.  In 
other  places,  sandarac  followed  with  thin  oil  is  a  good  separator. 

One  can  readily  understand  that  it  is  necessary,  in  separating  irregular  surfaces 
and  frail  forms  of  plaster  casts  from  each  other  and  from  the  flask  without  breaking, 
that  all  surfaces  must  be  arranged  to  drcnv,  and  then  covered  with  a  good  separating 
material.  In  separating  the  most  difficult  facial  casts  from  plaster  impressions,  a 
thick  coating  of  sandarac  varnish  is  used,  followed  by  soaking  in  water.  But 
soaking  in  water  weakens  cleft  palate  plaster  casts  and  renders  frail  portions  liable 
to  break.  In  the  construction  and  necessary  duplication  of  the  many  plaster  casts 
for  each  cleft  palate  case,  do  not  forget  that  the  flask  should  be  thoroughly  cleaned, 
and  its  beveled  surfaces  oiled  after  the  removal  of  every  plaster  casting,  which 
should  never  be  left  in  the  flask  long,  as  rust  will  soon  make  its  removal  difficvilt. 
The  success  of  the  entire  operation  demands  the  highest  order  of  cleanliness  and 
accuracy  at  every  step  of  the  undertaking. 

The  Plaster  and  Investment  Models 

In  the  process  of  pouring  the  plaster  models  the  plaster  should  be  of  just 
the  right  consistency  which  is  best  obtained  in  the  manner  described  in  filling  the 
impression.  With  the  flask  held  in  one  hand,  pour  the  plaster  from  the  bowl  into 
the  mold,  commencing  at  an  extreme  border  causing  it  to  flow  rapidly  over  the 
surfaces,  and  then  with  a  quick  movement  throw  it  back  into  the  bowl,  repeating 
the  movements  until  it  is  filled.  This  should  drive  the  air  out  of  all  the  pockets. 
Scrape  the  surplus  plaster  oft"  even  with  the  edge  of  the  flask. 

Fig.  29  represents  the  lingual  aspect,  after  the  dough  has  been  removed,  show- 
ing the  original  plaster-model  A  with  the  obturator-model  in  position  in  the  lingual 
half  of  the  flask  and  resting  now  upon  the  plaster  nasal  model  B,  which  has  just 
been  poured  into  the  flask,  and  finished  read\'  for  pouring  the  plaster  palatal  model 
C,  Fig.  31.    Remember  after  each  plaster  and  investment  model  is  poured,  all 


1()2 


PART   IX.     THE   PKOSTIIETIC  COKKhlTlOX   (U-    CI.Eh'T   J'A/.ATE 


the  parts  slimild  \)r  removed  from  the  flask  for  linishiiiL^  the  newly  jjoured  model 
and  preparing  the  flask  for  the  next  pouring.  In  removing  the  plaster  models  from 
the  ilask  after  pouring,  the  flask  is  In-ld  loosely  in  the  hand  with  the  fingers  and 
thumb  doubled  under  and  lightly  touehing  the  edges  of  the  model  to  prevent  it 
from  suddenly  falling  out  and  breaking,  the  flask  is  then  tapped  sharply  with  a 
light  hammer  on  the  under  side  of  one  of  its  ends,  the  fingers  being  able  to  detect 
and  guide  the  slightest  movement  of  the  model  as  it  falls  from  the  flask.     If  the 


Fui.  31. 


Vu..  '.'A. 


Fig.  S2. 


Fig   33. 


Lengthwise  sectional  views  through  the  plaster,  investment,  and  obturator-models. 


The  above  shows  the  Models  A  and  C  in 
the  flask  with  the  dough  placed  prepara- 
tory to  pouring  the  Investment  Model  E. 


plaster  model  clings  to  the  model  of  the  veil,  showing  that  it  has  lapped  beyond  its 
true  drawing  line,  loosen  it  carefully  with  a  spatula.  After  its  removal,  its 
finishing  consists  in  correcting  all  drawing  and  overlapping  lines  at  "v"  "v"  and 
parting  edges  at  "u"  "u,"  Fig.  34. 

Before  returning  the  casts  to  the  flask,  varnish  only  the  surfaces  that  are  to 
come  in  contact  with  the  next  model  to  be  poured.  Finally,  if  oil  is  used  over  the 
surfaces  of  the  mold  before  pouring,  stand  the  flask  on  edge  that  the  excess  oil 
in  pockets  may  drain  oft'. 

One  of  the  most  important  movements  in  the  whole  process  is  to  secure  abso- 
lute coaptation  of  the  models  at  "g"  and  "x,"  Fig.  31,  in  replacing  them  in  the  flask 


CHAPTER   V.    LABORATORY  TECHNIC  CONSTRUCTION  463 

preparatory  to  pouring  subsequent  plaster  or  metal  casts.  This  is  especially 
imperative  preparatory  to  pouring  the  models  B  and  C  around  the  model  A,  Fig. 
31,  or  in  fitting  together  the  subsequent  investment  models  (E  and  D,  Fig.  33) 
to  form  a  mold  for  duplicating  this  important  model  A  in  plaster,  or  metal ;  it  being 
a  duplicate  of  the  cleft  and  the  hard  surfaces  which  the  obturator  must  exactly 
fit.  If  an  excess  of  separating  fluid  or  a  slight  particle  of  plaster  or  dirt  is  allowed  to 
come  between  the  contact  surfaces  of  the  models,  or  between  them  and  the  beveled 
surfaces  of  the  flask,  which  might  arise  with  a  slovenly  procedure,  so  that  the  models 
A  and  B,  or  B  and  C,  do  not  come  absolutely  together,  the  same  misfit  will  be  pro- 
duced that  would  arise  if  the  nasal  and  palatal  sections  of  the  impression  are  not 
exactly  replaced.  Again,  the  expansion  of  the  plaster  models  will  at  times  make  it 
impossible  to  properh"  replace  them  in  the  flask.  This  should  be  corrected  by 
scraping  their  outer  surfaces  where  they  come  in  contact  with  the  flask.  Further- 
more, the  models  should  be  grasped  in  such  a  manner  during  the  process  of  pouring, 
that  they  can  be  held  firmly  together  until  the  first  stage  of  hardening  has  taken 
place. 

All  of  these  lengthy  preliminary  directions,  which  need  not  be  repeated,  are 
of  especial  importance  preparatory  to  the  final  duplications  in  metal,  which  may 
frequently  require  a  number  of  recastings  before  a  perfect  cast  is  secured,  and  which 
means  also  the  reduplication  of  the  investment  models,  if  they  are  broken. 

Fig.  31  illustrates  a  side  view  of  a  vertical-median  section  after  pouring  the 
plaster  palatal  model  C.  The  model  of  the  obturator  is  now  completely  surrounded 
with  parts  in  plaster,  which  when  duplicated  in  metal  and  properly  prepared,  will 
form  the  final  castings  in  which  the  rubber  obturators  are  vulcanized.  This  com- 
pletes the  first  set  of  models,  all  of  which  should  be  carefully  preserved;  first,  to 
enable  making  the  investment  sets  for  pouring  the  casts,  and  second,  as  original 
patterns,  by  the  aid  of  which — in  case  of  an  accident — a  new  set  of  metal  casts  or 
parts  thereof  can  be  made. 

Trim  the  top  and  bottom  surfaces  even  with  the  flask,  and  then  with  the 
nasal  model  B  downward,  tap  the  flask  gently  on  the  underside  with  precautions 
as  described,  and  when  B  is  removed,  trim  oft'  any  surplus  plaster  from  the  inside 
of  the  flask  which  may  have  run  down  between  it  and  the  nasal  model,  etc. 

In  like  manner,  the  models  A  and  C,  containing  the  obturator-model,  are 
removed  from  the  flask,  the  model  C  should  be  carefully  separated  from  the  model 
A  and  the  obturator-model.  As  it  would  be  impossible  to  remove  the  obturator- 
model  from  the  plaster-model  A,  because  of  the  added  portion  at  "d,"  Fig.  21 — 
and  also  for  other  reasons — it  is  necessary  to  saw  the  plaster-model  A  in  two,  along 
the  line  "t,"  Fig.  34,  using  a  very  thin  "jeweler's  saw,"  and  cut  nearly  to  the  ob- 
turator-model, and  then  hrcdk  the  two  halves  apart  by  inserting  a  thin  pry,  and 
carefully  separate  them  from  the  obturator-model.  See  that  the  edges  of  the  added 
portions  of  plaster  "d,"  Fig.  21,  are  smoothed  even  with  the  lines  of  the  model  A, 
and  remove  all  portions  of  plaster  which  may  have  been  extended  out  upon  the 


464  PARI'   /.v.     ////•;   PROSTIIIiTIC  CORRECTION  Of  CLKFT   PALATE 

surfaces.  The  object  in  breaking  tlic  rest  of  the  sawed  cut  instead  of  sawing  it  all 
the  way  through,  is  to  prevent  the  right  and  left  models  A,  in  subsequent  move- 
ments, from  closing  thccutand  tliusclianging  their  lnu>  relative  positions.  Separat- 
ing the  model  A  into  two  pieces  is  necessary  also  for  the  castings  to  enable  an  easy 
remowal  of  the  hard  obturators  after  vulcanizing. 

The  Investments  to  Form  the  Mold  for  the  Metal  Casts  A 

It  is  evident  that  if  these  plaster  models  which  surround  and  invest  the  obtura- 
tor-model are  to  be  duplicated  in  metal,  each  part  must  be  regarded  as  a  mold- 
er's  pattern,  or  model,  to  be  invested  or  surrounded  with  other  parts  composed 
of  some  material  against  which  metal  can  be  poured,  and  so  arranged  that  the  parts 
can  be  opened,  the  pattern  or  model  cleanly  removed  without  dragging,  and  the 
parts  accurately  readjusted  to  form  an  exact  mold  or  impression  into  which  the 
metal  is  poured  for  the  casts.  It  is  evident  also,  that  there  is  no  further  need  of 
the  obturator-model,  since  we  have  the  impression  of  all  its  surfaces  in  the  form 
of  a  mold,  still  it  is  well  to  preserve  it  intact  in  case  some  unforeseen  accident 
occurs. 

It  is  advisable  to  make  the  metal  casts  of  the  model  A  first,  because  it  is  usually 
the  most  difficult  to  obtain,  with  the  absolute  accuracy  required  of  the  nasal 
and  palatal  surfaces.  It  is  also  necessary  to  make  the  subsequent  investments  and 
metal  duplicates  of  this  model  in  two  pieces,  as  explained. 

Investment  Models 

Fig.  34  is  a  nasal  view  of  the  model  A,  and  the  palatal  model  C  in  position 
in  the  lingual  part  of  the  flask  with  tlu-  obturator-model  removed,  preparatory 
to  pouring  the  investment  nasal  model  D  (Fig.  32),  which  is  to  form  part  of  the 
mold  for  casting  the  right  and  left  du]jlicates  of  the  model  A.  It  will  be  noticed 
that  the  space  which  was  filled  by  the  lingual  portion  of  the  obturator-model  is 
now  filled  with  dough  up  to  the  line  which  represents  the  nearest  approaching  bor- 
ders of  the  cleft  (Fig.  34),  for  the  purpose  of  stopping  the  plaster  at  that  point. 
The  lingual  cover  of  the  flask  is  now  placed  and  fastened  with  the  pins  to  prevent 
the  models  from  moving.  The  exposed  surfaces  of  the  models  are  covered  with 
two  coats  of  Brophy's,  or  any  good  separating  fluid,  carefully  oiled  and  drained, 
and  then  the  flask  is  filled  with  any  good  investment. 

In  describing  the  method  of  obtaining  metal  casts  for  the  Kingsley  Velum 
('Cosmos,  June,  1885),  the  author  employed  sand  for  the  molds;  but  for  many  years 
some  of  the  market  mixtures  of  investments  have  been  far  preferable.  Choose  an 
investing-compound  that  will  pour  easily,  leave  a  smooth  surface,  become  very 
hard,  and  that  will  sustain  considerable  heat  without  shrinking  or  cracking,  and 
will  not  break  in  separating  it  from  the  casting.  This  is  important  in  the  effort 
to  produce  exact  duplication  and  to  avoid  the  possible  necessity  of  making  a  whole 
new  set  of  investment  models  in  case  a  metal  cast  is  imperfect. 


CHAPTER   V.    LABORATORY   TECHNIC  CONSTRUCTION  465 

Fig.  32  illustrates  a  transverse  section,  showing  the  investment  D  in  place 
after  being  poured.  When  this  is  hard,  all  the  models  are  removed  from  the  flask 
and  the  surfaces  prepared  for  the  next  investment  model.  With  the  plaster  palatal 
model  C,  and  the  dough  removed,  and  the  plaster  model  A,  and  investment  model 
D  in  position,  the  investment  model  E  is  povxred.    Fig.  33. 

It  will  be  seen  that  the  space  which  was  occupied  by  the  obturator-model 
is  now  entireh-  closed,  and  that  any  one  of  the  component  parts  can  be  readily 
duplicated  by  removing  it  and  filling  the  space  which  it  occupied.  As  it  is  necessary 
to  duplicate  in  metal  the  casts  of  the  model  A  in  two  parts,  one-half  of  this  model 
is  removed  (Fig.  35,  Chapter  VI),  and  the  space  is  then  filled  with  investing-com- 
pound  forming  one-half  of  investment  model  A.  Before  and  during  the  pouring 
of  this  model  with  investment  or  metal,  the  parts  in  the  flask  should  be  exactly 
fitted  and  held  firmly  together,  as  any  variation  in  this  will  detract  from  the  fit 
of  the  obturator.  After  pouring  this  investment  model  A,  remove  the  entire  model 
A  and  smooth  the  surface  of  the  investment  where  it  joins  the  sawed  surface  of  its 
fellow.  It  will  then  be  seen  if  the  parts  were  exactly  together,  and  if  not,  another 
should  be  poured. 

Fig.  36  shows  the  space  after  the  removal  of  the  other  half  of  the  plaster-model 
A.  The  case  is  now  composed  entirely  of  investment-compound,  and  ready  for 
pouring  the  first  metal  cast  A.  Before  drying  the  investment-models  for  this  pur- 
pose, it  is  always  advisable  at  this  stage  to  make  new  exact  duplicates  of  the  original 
plaster  model  A,  in  case  the  original  is  broken.  This  is  easily  done  by  pouring  new 
plaster  halves  of  the  model  A  in  the  spaces  which  they  occupied,  commencing 
as  arranged  for  the  metal  cast  in  Figs.  35  and  36. 


CHAPTER  \  1 
TECHNICS   OF   TUV.    MI'.TAL    CAS'I'S   AND   OBTURA'I'OR 

The  metal  casts  of  tlu'  right  and  left  plaster  models  A  are  obtained  as  follows: 
With  the  investments  in  place  in  the  flask,  as  shown  in  Fig.  36,  and  the  nasal  cover 
secured  in  position  with  the  pins,  thoroughly  dry  the  case  until  not  a  particle  of 
moisture  appears  on  a  cool  dry  piece  of  glass.  Haskell's  Babbitt  metal  has  been 
foimd  to  produce  the  most  satisfactory  castings.  This  is  especially  mentioned, 
as  there  is  such  a  vast  difference  in  the  general  commercial  product  of  this  metal. 


Fig.  sri. 


Fii..  :!(), 


It  possesses  a  favorable  degree  of  fusibility  and  should  make  a  sharp  casting  with- 
out shrinkage.  During  the  pouring,  hold  the  case  in  one  hand  with  a  padded  hold- 
er, with  the  thumb  pressing  firmly  the  palatal  investment  E,  and  jog  the  case  by 
striking  the  back  of  the  hand  upon  the  bench.  This  will  cause  the  metal  to  flow 
sharply  and  the  air  bubbles  to  rise  to  the  top  in  case  of  air  pockets.  Before  the 
metal  has  congealed,  the  excess  should  be  quickly  scraped  off  even  with  the  top  of 
the  flask.  One  should  never  get  discouraged  if  he  has  to  pour  several  casts  before 
one  is  secured  that  is  perfect,  though  this  may  rarely  happen. 

466 


CHAPTER    VI.     TECHNICS  OF   THE  METAL  CASTS  AND  OBTURATOR 


467 


After  pouring,  as  soon  as  the  casting  has  cooled  sufficiently,  remove  the  invest- 
ments and  metal  cast  A,  from  the  lingual  half  of  the  flask  by  gently  tapping  the 
flask  on  the  side  so  that  they  will  all  fall  out  together.  Then  carefully  part  them  from 
the  metal  cast  A,  with  the  view  to  prevent  fracturing  the  now  more  or  less  fragile 
palatal  investment,  and  thus  avoid  the  necessity  of  making  new  ones  with  the 
lengthy  dr}-mg  process  for  the  casting  of  the  other  half  of  the  model  A,  or  for 
the  recasting  of  the  first  one  in  case  it  is  found  imperfect. 

Each  metal  castiii<^  <is  it  is  ohtiiiiied  is  Iwnccfortli  used  (is  <i  pxirt  of  tlic  roi)!l)i)i(itioii 
in  the  flask  for  subsequent  castings;  the  exposed  surfaces  to  be  poured  against  ])eing 
covered  with  a  thin  coating  of  plumbago.  If  the  first  pouring  of  the  metal  cast  A 
is  found  to  be  perfect,  it  can  be  immediately  replaced  in  the  flask  with  the  Invest- 
ment E  (if  not  broken )  and  without  further  drying  (if  it  is  still  hot )  the  second  half 
of  the  cast  A  can  be  poured. 

When  the  two  pieces  which  form  the  metal  duplicates  of  the  model  A  are 
secured,  the  next  castings  to  be  obtained  are  the  duplicates  of  the  original  nasal 
and  palatal  models  B  and  C,  which  surround  the  model  of  the  obturator.    Fig.  31. 

The  Metal  Casts  of  the  Original  Plaster  Models  B  and  C 

It  makes  no  difterence  which  of  the  two  remaining  models  of  the  original  set 
is  cast  first,  though  it  is  usually  easier  to  duplicate  the  nasal  cast  B  last.  In  this 
description,  however,  the  nasal  cast  B  is  made  first,  i.  e.;  Place  the  right  and  left 
metal  castings  A  in  the  flask  with  the  original  plaster  nasal  model  B,  Fig.  37. 

Fig.  37. 


Before  doing  this  secure  a  perfect  coaptation  of  tlie  contact  surfaces  of  the  metal  casts 
and  plaster  model,  especially  along  the  border  "y"  which  may  be  understood  as 
representing  the  entire  border  of  the  nasal  portion.  The  interferences  to  the  perfect 
coaptation  of  the  plaster  and  metal  pieces  are  commonly  due  to  imperfections  of  the 
metal  castings  at  their  outer  borders  next  to  the  flask  where  they  have  followed 
slight  fractures  of  the  investment  model.  The  fitting  is  usually  done  outside  of  the 
flask,  either  by  cutting  away  the  metal  or  the  plaster  at  interfering  points.  Finally, 
see  that  the  surface  of  the  plaster  model  B  is  well  coated  with  lubricants,  and  the 
nasal  cover  of  the  flask  secured  in  place  to  prevent  the  slightest  displacements. 
Then  pour  investment  G  jogging  it  so  that  it  will  flow  and  completely  fill  to  their 
very  outer  borders  the  deep  interspaces,  w'hich  represent  the  nasal  extensions  of 


4()8 


PART   IX.     rill'.    /'ROSTI/ETIC  CORR/'XT/OX   Of  CLEFT   J'ALATE 


Fig.  38. 


the  obturator.  It  helps  to  .shorten  the  time  of  the  (hyin^'  out,  in  casting  duphcates 
of  models  B  and  C,  by  using  no  more  investment  material  than  is  necessary  to 
represent  the  desired  impression  surfaces  of  the  model  to  be  duplicated. 

When  the  investment  is  hard,  the  nasal  cover  of  the  flask  is  removed,  and 
the  plaster  nasal  model  B  alone  is  carefully  removed  from  the  flask  by  lightly 
tapping  tlie  flask  as  before  described.  If  the  adjustments  have  been  perfect,  little 
or  no  investment  will  have  flowed  out  upon  the  castings  beyond  the  designated 
borders  of  the  obturator.  If  this  has  occurred,  however,  to  a  slight  extent,  remove  it 
and  define  the  borders.  Again,  if  the  investment  has  not  wholly  filled  the  space,  or 
air-holes  have  arisen,  they  should  be  filled.  When  it  is  remembered  that  in  this 
impressional  surface  is  represented  the  entire  upper  nasal  surface  of  the  obturator, 
with  t>ne-half  the  border  of  the  veil,  it  will  be  seen  that  it  should  be  regarded  as 
a  model  of  that  part  of  the  obturator  and  finished  to  represent  the  proper  thickness 
and  extensions  of  the  nasal  wings,  and  evenly  defined  borders  throughout.  Slight 
changes  which  seem  advisable  toward  rednciiif^  the  size  or  thickness  of  the  original 
obturator-model,  may  be  made  at  this  time  without  harm,  in  as  much  as  it  is  pos- 
sible to  make  corrections  by  enhirging  the  final  castings.  The  surfaces  of  the  invest- 
ment at  the  posterior  edges  of  the  castings  at  "u,"  Fig.  34,  should  be  made  to  join 
evenly,  and  the  excess  of  plaster  removed  from  the  sides  of  the  flask  above  its  divid- 
ing beveled  line  "v." 

When  properly  prepared,  the  metal  surfaces  are 
coated  with  plumbago;  the  case  is  then  thoroughly 
dried,  and  the  metal  cast  of  B  is  poured  in  the  same 
manner  as  described  for  the  castings  of  A.  Great 
care  should  be  exercised  to  prevent  melting  the 
metal  casts  which  are  in  the  flask  while  drying  the 
investments  for  pouring  subsequent  castings.  The 
danger  point  of  heat  may  be  determined  by  placing 
a  small  fragment  of  the  metal  on  the  heater  beside 
tlie  flask,  'i'liis,  when  it  starts  to  melt  will  be  a 
warning  to  reduce  the  heat. 

When  the  metal  cast  B  is  secured,  the  original 
plaster  model  C  (Figs.  31  and  38),  next  to  be  du- 
plicated, is  fitted  to  the  metal  casts  in  the  same 
manner  as  described  for  B.  As  it  is  necessary  to 
press  this  plaster  model  C  firmly  to  place — after 
sufficient  investment  material  has  been  placed  in  position  to  fill  the  interspaces 
occupied  by  the  obturator-model — numerous  gates  should  be  cvit  extending  to  the 
top  edge  of  the  cast  for  the  free  overflow  of  investment.  See  Fig.  38.  In  the  fitting 
of  the  plaster  model  C,  the  seating  "g,"  Figs.  29  and  37,  of  the  metal  cast  A,  should 
be  corrected  and  polished,  though  not  to  change  the  sharply  outhned  edge  of  the 
obturator,  where  there  should  be  perfect  coaptation  of  the  casts.    After  thoroughly 


CHAPTER    VI.     TECHNICS  OF   THE  METAL  CASTS  AND  OBTURATOR         469 

preparing  the  surfaces  of  the  model  C  for  separating,  as  described  with  B,  and  with 
the  metal  casts  A  and  B  in  the  flask  secured  with  the  nasal  cover,  place  only  the 
required  amount  of  investment  in  the  mold  to  fully  fill  the  interspaces;  then 
press  the  plaster  model  C  firmly  to  place,  holding  it  in  position  until  the  invest- 
ment is  partially  hard.  It  will  be  seen  that  if  this  cast  does  not  go  fully  to  place, 
the  only  harm  it  does  is  to  thicken  the  palatal  and  veil  portion  of  the  obturator 
beyond  that  which  was  designed  to  be  the  proper  dimensions  when  the  obturator- 
model  was  prepared.  If  this  thickened  condition  is  more  than  a  slight  scraping  of 
the  plaster  surfaces  will  correct,  all  the  casts  should  be  removed  from  the  flask,  and 
cleaned  and  freed  from  every  possible  obstruction  that  may  have  prevented  them 
from  being  forced  fully  to  place.  It  may  be  that  the  plaster  model  C  has  slightly 
expanded,  indicating  that  the  surfaces  which  join  the  flask  should  be  scraped.  More 
than  likely  the  investment-compound  was  mixed  too  thick,  etc. 

In  the  removal  of  the  plaster  model  C,  great  care  should  be  used  so  as  to  not 
dislodge  or  cause  the  slightest  movement  of  the  metal  casts  A,  lest  the  thin  invest- 
ment extensions  which  represent  the  palatal  wings  are  thrown  from  their  seating 
on  the  casts.  This  may  be  accompHshed  by  holding  the  casts  firmly  in  place  with 
the  fingers  while  the  model  is  tapped  lightly,  without  turning  the  flask  over.  It 
then  may  be  carefully  lifted  with  a  screw-driver  thrust  into  the  posterior  hole  or 
if  one  dislikes  to  disturb  the  stopping  of  this  hole,  which  would  necessitate  filling 
it  again,  the  model  C  can  be  lifted  from  its  seating  by  prying  it  up  from  the  back 
with  a  sharp  pointed  knife.  One  can  see  by  this  the  need  of  perfect  lubrication 
of  model  C,  before  pressing  it  to  place.  After  the  removal  of  model  C,  all  ex- 
cess investment  which  covers  the  metal  casts  A  and  B,  beyond  the  defined 
borders  of  the  obturator,  should  be  removed.  It  will  be  seen  that  the  investment- 
impression  at  this  stage  is  a  duplicate— or  should  be — of  the  entire  lingual  surfaces 
of  the  obturator-model.  Before  pouring  the  metal  cast  C,  all  the  metal  surfaces  of 
the  mold  should  be  covered  with  plumbago,  the  lingual  cover  of  the  flask  is  fastened 
in  place,  and  the  case  is  thoroughly  dried,  etc.,  as  before  described. 

Note:  As  before  stated,  if  it  is  found  after  pouring  each  of  the  metal  casts 
A,  B,  or  C,  that  they  are  imperfect,  due  mostly  to  not  sufficiently  drying  the 
investments,  and  if  it  is  found  also,  that  the  investments  are  not  broken,  as  should 
obtain  with  good  material,  another  cast  should  be  poured  at  once,  as  the  heat  of  the 
first  casting  may  have  completed  the  drying  of  the  investment.  In  fact,  several 
pourings  are  often  made  with  the  same  investment. 

Preparatory  to  Packing  and  Finishing  the  Obturator 
The  casts  are  now  finished  and  polished  on  all  the  oi^turator  surfaces,  except 
those  which  represents  the  nasal  and  lingual  surfaces  of  the  castings  A,  which 
are  simply  brushed  and  burnished.  The  entire  inside  surfaces  of  the  casts  are 
then  covered  with  a  coating  of  common  bar  washing  soap  to  prevent  the  rubber 
from  clinging  to  the  casts  upon  removal.    Heavy  tin-foil  may  also  be  used  for  this 


470 


I' ART   IX.     rilli  PROSTHETIC  CORRECTION   OE  CLEET   I'M. ATE 


purpose',  which  is  especially  desirable  when  the  \-eluni-()l)tnrator  is  to  be  made  of 
flexible  rubber,  because  of  the  impossibility  of  furllu'r  fmishin.L,'  llie  soft  rubber 
after  vulcanizing. 

The  case  is  warmed  and  packed  similar  to  that  of  dental  rubber  plates.  Re- 
member that  the  fusibility  of  Babbitt's  metal  is  much  lower  than  lead  and  that  an 
excess  of  heat  through  forgetfulness,  etc.,  may  spoil  all  the  work.  In  packing,  do 
not  use  an  excess  of  rubber.  The  amount  may  be  roughly  estimated  by  the  weight 
or  by  the  water  displacement  of  the  obturator-model.  Force  the  casts  to  place  in  a 
press  after  packing,  and  continue  by  placing  the  whole  in  boiling  water  until  the 
lingual  and  nasal  covers  of  the  flask  can  be  fully  fastened  with  the  pins.  After 
vulcanizing,  warm  in  hot  water  and  insert  a  screw-driver  into  one  of  the  holes 
in  the  sides  of  the  flask,  and  carefully  pry  the  casts  apart,  etc.  The  finishing  is 
similar  to  that  of  rubber  dental  plates. 

Notwithstanding  the  very  great  dift'erence  in  the  sizes  of  congenital  clefts 
of  the  palate,  the  principles  involved  in  the  technic  are  the  same,  with  slight 
variations  to  meet  differences  in  form.  Moreover,  the  forms  of  obturators  are  all 
quite  .similar  in  their  general  characteristics  as  shown  in  Fig.  39,  from  open  double- 
clefts  to  the  one  on  the  right  of  the  lower  row  for  a  cleft  extending  into  the  hard 
palate  about  three-eighths  of  an  inch  only. 

Fig.  aft. 


tt£ 


i4<a 


There  is  no  reason  in  the  world  why  the  general  practitioner  of  dentistry 
should  not  consider  the  whole  operation  of  the  prosthetic  correction  of  cleft  palate 
as  a  part  of  his  profession,  because  it  is  so  similar  in  its  mechanical  reciuirements 
to  that  in  which  he  is  necessarily  skilled.  It  certainly  would  result  in  bringing 
incalculable  relief  and  happiness  to  the  lives  of  thousands  of  sufferers,  because  it 
would  Restore  to  them  the  fair  opportunities  of  humanity  for  intellectual,  social, 
and  commercial  advancement.  It,  moreover,  would  prevent  many  harmful 
surgical  operations. 


CHAPTER  MI 

COMPLICATION'S   WITH    IRRI'.Cl'LARITIKS    AXD    SURGICAL    FAILURES 

With  all  extensive  congenital  clefts,  especially  among  those  which  extend  entirely 
through  the  maxillary  bone  at  one  side  of  the  incisive  process  or  both,  and  also 
through  the  lip,  there  commonly  arise,  through  a  lack  of  normal  development, 
abnormalities  of  the  upper  jaw  and  denture.  These  conditions  are  frequently  of 
such  a  serious  character  that  they  demand  correction  preliminary  to  the  insertion 
of  the  obturator  if  one  hopes  to  obtain  a  condition  that  will  enable  the  patient 
to  acquire  perfect  articulation,  to  say  nothing  of  the  desirability  and  advantage 
of  correcting  decided  facial  deformities. 

Malpositions  and  lack  of  development  of  upper  front  teeth,  loss  of  the  entire 
intermaxillary  process  and  incisor  teeth  in  double  clefts,  lack  of  development  of 
bone  with  decided  malpositions  and  impactions  of  anterior  teeth  in  complete 
single  clefts,  with  consequent  retractions  and  retrusions  of  the  teeth  and  anterior 
supporting  processes,  have  quite  as  much  influence  in  preventing  the  distinct  enun- 
ciation of  certain  oral  elements  of  speech  as  has  the  cleft  of  the  palate  itself.  Im- 
perfect surgical  operations  on  the  upper  lip  leaving  the  patient  with  V-shaped  fis- 
sures and  an  excess  of  cicatricial  tissue,  will  frequently  mar  the  correct  articulation 
of  labials  and  labial  explosives  which  demand  distinct  utterance.  One  occasionally 
meets  with  the  surgical  results  of  an  operation  on  a  double-fissured  lip,  with  and 
without  the  intervening  incisor  teeth  and  process,  which  in  the  contracted,  re- 
truded,  and  tightly  drawn  cicatricial  condition  of  the  upper  lip  destroys  its  natural 
contour  and  functional  activities.  Skillful  plastic  surgery  will  accomplish  wonders 
in  the  restoration  of  these  cases. 

Labial  explosives  as  in  bu,  boy,  etc.,  demand  for  a  perfect  acquirement  of 
distmct  enunciation  a  perfect  closure  of  the  lips,  w^hich  is  impossible  if  there  is  the 
slightest  opening  through  which  the  compressed  breath  can  escape.  Labio  and 
linguo-dentals,  as  in  vu,  vain,  fu,  fall,  and  thii,  those,  etc.,  require  an  even  line  of 
occlusal  edges  of  the  upper  front  teeth.  The  anterior  linguo-palatals,  both  ex- 
plosives and  aspirates,  in  words  containing  the  oral  elements,  tu,  du,  chu,  s,  z, 
and  sh,  cannot  be  perfectly  uttered  without  an  occluding  surface  for  the  tongue, 
which  resembles  in  its  form  the  anterior  linguo-palatal  ridge. 

In  extensive  cases  it  is  rare  to  find  the  full  complement  of  teeth,  impacted 
or  otherwise,  the  germs  being  extinct  or  having  been  destroyed.  In  two  instances 
in  the  author's  practice,  the  intermaxillary  or  incisive  process  and  the  incisors  were 
missing,  which  was  doubtless  caused  by  the  surgeon  who  operated  on  the  lip  in 
early  infancy  not  understanding  that  the  nodidar  fleshy  process,  hanging  at  the 

471 


472  I'ART    IX.     rilh:   PROSTHETIC  CORRECTIOX   OF  CLEFT   PALATE 

tip  end  of  llic  nose  at  birth  with  nifants  having  duublu  clefts  and  hare-Hps,  ccjntains 
the  germs  of  an  important  part  of  dental  and  facial  anatomy.  Believing  it  to  be  a 
useless  abnormal  appendage,  these  "would  be  surgeons"  heedlessly  snip  it  off, 
oblivious  of  the  fact  that  they  are  depriving  the  patient's  future  of  the  main  portion 
of  the  upper  lip,  all  the  upper  incisor  teeth  and  the  entire  intermaxillary  process 
with  its  nasal  spine  and  cartilaginous  septum  supporting  the  upper  lip  and  the  end 
of  the  nose. 

Even  with  extensive  single  complete  clefts  through  the  maxillae,  some  of  the 
front  teeth  are  commonly  missing,  others  are  frequently  deformed,  decidedly 
malposed,  or  deeply  impacted,  so  that  orthodontic  and  prosthodontic  operations  are 
demanded,  if  one  aspires  to  accomplish  a  perfect  correction.  If  in  these  cases 
it  seems  necessary  to  sustain  the  obturator  with  a  plate  denture — which  is 
now  rare  in  this  stage  of  our  advancement — a  gold  plate  denture  may  be  constructed 
with  a  pink  rubber  attachment  to  restore  the  facial  contour  and  fill  the  anterior 
portion  of  the  cleft.  But  a  removable  bridge  denture  with  porcelain  restorations  is 
preferable  by  far.  It  is  nearly  always  advisable  in  these  cases  to  first  correct  the 
positions  of  the  remaining  teeth,  and  widen  the  arches.  In  wide-open  clefts  at  birth, 
the  space  in  front  will  usually  be  found  closed  at  ten  years  of  age,  however  much  the 
jaw  may  be  deprived  of  front  teeth  and  intermaxillary  processes.  This  extensive 
settling  together  of  the  two  lateral  sections  of  the  maxilla  is  partly  due  to  the 
contracting  force  of  the  surgically  closed  upper  lip,  wluch  also  causes  the  decided 
upper  retrusion  so  often  found  in  these  cases. 

Besides  correcting  the  alignment  of  the  remaining  teeth,  the  restoration  of 
impacted  teeth  and  the  extraction  of  deformed  teeth,  the  cleft  maxillae  should  be 
widened  to  restore  the  parts  to  their  normal  positions  in  order  to  place  the  buccal 
teeth  in  masticating  occlusion  with  the  lowers  and  to  round  out  the  arch  for  the 
proper  placing  of  the  artificial  denture  and  restoration  auxiliaries.  The  extensive 
lateral  expansion  of  the  arch  will  of  course  widen  the  cleft,  but  that  is  a  matter  of  no 
moment  so  far  as  the  fitting  and  action  of  the  obturator  is  concerned,  while  the  cleft 
forward  of  it  can  be  cjuite  as  easily  and  properly  closed. 

The  strong  tendency  of  the  widened  arch  and  cleft  to  go  back  to  its  former 
position  demands  a  firmly  attached  fixed  retaining  bridge.  If  a  removable  bridge 
is  employed,  it  must  be  of  that  construction  which  will  eft'ectually  prevent  this 
possibility.  There  is  such  a  variety  of  conditions  that  will  arise  no  rules  can  be 
laid  down,  as  much  will  depend  upon  the  ingenuity  and  skill  of  the  operator. 

Fig.  40  made  from  the  dental  easts  of  a  girl  15  years  of  age,  illustrates  a  case  on 
the  left  in  which  a  wide  anterior  cleft  bereft  of  the  entire  intermaxillary  portion 
had  become  closed  in  front,  so  that  the  right  cuspid  nearly  touched  the  second 
premolar  on  the  opposite  side — the  loss  of  the  intervening  teeth  and  tissues  doubtless 
occurred  from  the  cause  referred  to.  In  observing  the  decidedly  abnormal  retruded 
position  of  the  remaining  front  teeth  in  relation  to  the  lower  denture,  one  can  im- 
agine something  of  the  facial  deformity  which  this  produced,  as  shown  on  the  left 


CHAPTER    VII.     IRRKGLLAR/TIES   A\D  SLRGICAL   J  WILL  RES 


473 


of  Fig.  41.     On  the  right  of  Fig.  40  will  be  seen  the  expanded  arch  and  corrected 
position  of  the  teeth,  resulting  in  a  good  masticating  occlusion  of  the  buccal  teeth, 


Fk;.  40. 


Fic.  11. 

r 

r^ 

r^ 

I 

'!/m 

'  ^ 

r        -a 

L 

^^^^^^^j 

lM 

lJ 

The  above  dental  and  facial  casts  show  U)  the  icsiills  following  the  deprivation  of  inteniia.\illar\"  process 
and  front  teeth,  with  the  abridged  and  cicatricially  contracted  upper  Up,  (2)  the  expanded  arch  and 
widened  cleft  in  preparation  for  the  restoration  denture  and  obturator,  and  (S)  the  final  completed 
conditions. 

preparatory  to  the  construction  of  the  removable  bridge  restoring  denture.  The 
central  facial  cast  below  was  made  after  the  dental  restoration,  and  the  one  on  the 
right,  after  the  plastic  operation  by  Dr.  L.  L.  McArthur  of  Chicago. 


474  PART   IX.     THE   PROSTHETIC  CORRECTION  OE  CLEET   PALATE 

With  tlic  restoration  of  the  facial  outhncs  and  functions  of  mastication,  and 
with  a  velum-obturator  which  enables  her  to  speak  with  perfect  articulation  and 
tone,  this  now  cjuite  attractive  looking  young  woman  is  a  useful  and  happy  member 
of  society,  endowed  with  all  the  possibilities  which  make  life  worth  the  living.  To 
one  who  has  accomplished  a  single  result  of  this  character,  the  fee,  be  it  little  or 
much,  is  nothing  compared  to  the  great  satisfaction  of  knowing  that  he  has  been 
instrumental  in  restoring  to  physical,  social,  and  intellectual  manhood  or  woman- 
hood a  deformed  human  being  whose  life  otherwise  would  have  been  a  constant 
embarrassment,  a  humiliation,  and  a  burden. 

One  patient  wearing  a  velum-obturator  delivered  the  valedictory  of  his  class, 
another  the  salutatory,  and  a  third — a  girl — the  class  poem.  Two  others  are  now 
practicing  law,  and  another  is  a  member  of  a  prominent  glee  club.  One  young 
man  gave  quite  a  remarkable  exhibition  in  an  extemporaneous  speech  at  the 
meeting  of  the  International  Dental  Congress  in  1904  at  St.  Lonis,  and  spoke  so 
perfectly  that  Dr.  Platschick,  a  prominent  Paris  dentist,  made  the  following 
remark  in  the  discussion:  "While  Dr.  Case  speaks  well,  his  patient  speaks  more 
distinctly.  At  least  it  is  easier  for  me  to  understand  him."  Many  other  patients 
might  be  mentioned  who  are  now  filling  prominent  positions  in  social  and  busi- 
ness life  which  would  have  been  otherwise  impossible  without  the  aid  of  these 
obturators. 

The  author  does  not  wish  to  infer  that  success  has  always  been  the  invariable 
result,  except  with  those  who  commenced  wearing  the  velum-obturators  under 
twenty-five  years  of  age;  though  a  number  learned  to  speak  perfectly  with  its  aid 
at  thirty-five  years  of  age,  and  one  after  forty  years  of  age. 

Fig.  42,  at  the  top,  illustrates  the  dental  casts  of  a  boy  at  fourteen  years  of  age. 
His  upper  central  incisors  besides  being  decidedly  retruded  and  malturned,  were 
almost  wholly  buried  under  the  gums.  The  right  cuspid  was  impacted,  and  the 
left  cuspid  just  pricking  through  the  gum  was  in  decided  mesial  inclination.  The 
width  of  the  arch  in  the  buccal  area  placed  the  molars  in  extreme  buccal  occlusal 
relation  to  the  lowers.  In  fact,  there  were  only  two  points  where  his  teeth  touched 
in  occlusion.  The  cleft  was  unusually  large  and  wide,  partly  due  to  loss  of  natural 
tissue  in  frantic  and  futile  surgical  operations  to  close  it  during  infancy.  His 
speech  was  so  imperfect,  becatise  of  his  extensive  palatal  and  dental  deformity, 
that  it  greatly  hindered  him  at  school  and  whenever  he  attempted  to  talk  to  stran- 
gers. And  yet,  he  was  a  boy  of  more  than  usual  intelligence  and  brightness,  just 
arriving  at  the  age  when  he  was  beginning  to  feel  intensely  the  humiliating  and 
depressing  forces  of  his  misfortune. 

The  impression  for  the  obturator  was  delayed  until  the  positions  of  the  teeth 
were  partially  corrected  as  shown  by  the  models  in  the  lower  half  of  Fig.  42,  which 
also  shows  his  obturator  in  position.  It  was  necessary  to  take  the  impression 
in  three  sections  in  this  case,  as  described  and  illustrated  in  Chapter  III.  This 
impression  shown  in  Fig.  13  was  photographed  before  filling  for  the  working-model. 


CHAPTER    VII.     IRREGULARITIES  AXD  SURGICAL   FAILURES 


475 


The  first,  or  test  obturator  was  of  flexible  ruljbcr,  but  before  the  close  of  the  day 
this  was  substituted  for  a  hard  poHshed  rubber  obturator,  which  remained  in  his 
mouth  during  that  first  night,  and  every  night  since,  without  a  retaining  plate. 
This  patient  was  presented  at  the  November,  1914,  meeting  of  the  Odontological 
Society  of  Chicago  about  two  weeks  after  the  first  insertion  of  his  obturator,  and 
even  at  that  early  stage  he  could  perfectly  articulate  nearly  all  the  oral  elements  of 
speech  when  pronounced  for  him  separately,  and  most  of  the  single  syllable  words 
which  are  difficult  for  cleft  palate  patients  to  utter. 

Fig.  42. 


The  above  shows  ilia  not  iinconiniun  lack  oi  de\"eiopnient  and  malccchision.  (2)  Below, 
the  partial  correction  of  the  upper  front  teeth,  preparatory  to  the  construction  of  an 
obturator  which  is  seen  in  place 


His  mother  wrote  the  author  about  a  year  afterwards :  "He  is  now  taking  his  place 
in  his  school  classes  with  the  greatest  satisfaction  to  his  teachers  and  friends,  speaking 
nearly  all  his  words  with  quite  distinct  articulation,  except  when  he  forgets  himself 
and  speaks  rapidly.  We  feel  it  will  not  be  many  months  before  he  completely 
corrects  these  former  habits  of  speech."  With  this  change  and  its  possibilities  in 
his  speech  and  voice,  there  will  come  into  his  countenance  the  happy  animated 
expression  of  boyhood  which  will  take  the  place  of  the  former  dull  look  of  despair. 

One  of  the  most  difficult  and  at  times  discouraging  conditions  which  confronts 
the  specialist  in  the  mechanical  treatment  of  cleft  palate,  is  the  appeal  for  help 
from  those  whose  clefts  have  been  partially  or  completely  closed  by  imperfect  or 
inadecjuate  surgical  operations,  which  leave  them  without  the  possibility  of  ever 
perfecting  their  speech  unless  something  else  can  be  accomplished. 


476  PART   l\.     THE  PROSTHETIC  CORRECTION   OE   CI.EET   PALATE 

It  is  a  mistaken  idea  aiiKJiig  surjijeons  that  an  c'(|ually  sncccssfnl  artificial  palate 
can  always  be  constrncted  after  surgical  operations  ijrove  t(.)  be  failures.  For  even 
in  those  cases  where  they  have  not  succeeded  in  uniting  any  portion  of  the  cleft, 
nnieh  will  depend  uixm  tlie  amount  of  scar  tissue  that  is  left,  which  will  propor- 
tionately inhibit  the  free  functional  mobility  of  the  palatal  muscles  upon  which  the 
obturator  almost  wholly  depends  for  its  perfect  action. 

A  common  form  of  surgical  failinx'  that  frecjuently  comes  before  the  author, 
and  one  which  is  more  unfortunate  than  no  surgical  union,  is  where  the  patient  is 
left  with  a  partial  closure  of  the  cleft — generally  through  the  velum — the  history 
of  which  usually  indicates  that  the  surgeon  was  unable  by  repeated  trials  to  close 
the  cleft  through  the  hard  palate.  On  the  other  hand,  many  operations  are  per- 
formed upon  extensive  clefts  with  the  view  of  closing  only  the  soft  palatal  cleft, 
in  the  very  wrongful  belief  that  when  the  remainder  of  the  cleft  is  closed  with  an 
artificial  plate,  which  any  dentist  can  construct,  the  patient  will  speak  intelligibly. 
At  any  rate  the  assurance  is  given  that  all  has  been  accomplished  that  is  possible 
for  the  patient.  The  statement  will  apply  here  that  was  mentioned  in  reference  to 
all  surgically  corrected  palates  that  are  decidedly  inadeciuate  in  length  for  closing 
the  oro-nasal  passage. 

The  most  imfortunate  feature  in  regard  to  all  cases  in  which  the  original  cleft 
extends  into  the  hard  palate,  and  which  is  united  surgically  only  at  the  soft  palate 
is:  the  fact  that  few  patients  are  willing  to  have  these  partially  united  palates 
disunited  for  the  insertion  of  an  obturator,  even  though  there  may  be,  through  this 
means,  a  fair  promise  of  all  the  possibilities  of  perfect  speech.  One  patient  over 
twenty-five  years  of  age  with  a  large  cleft,  and  with  only  a  small  part  of  the  cleft 
through  the  soft  palate  surgically  united,  after  hesitating  for  more  than  a  year 
before  permitting  its  disunion  for  the  obturator,  finally  consented  to  the  operation; 
and  then  because  of  a  favorable  decree  of  an  Oracle  which  he  said  he  had  consulted. 
This  man  who  was  a  foreman  in  a  large  machine  shop,  and  quite  well  educated, 
learned  to  speak  so  perfectly  with  an  artificial  palate  that  he  had  evening  classes 
for  teaching  the  foreigners  of  the  shop  to  speak  English  correctly. 

Fig.  43  shows  the  models  and  obturator  of  a  boy  twelve  years  of  age  whose 
soft  palate  when  presented  was  stirgically  united,  and  though  the  opening  through 
the  hard  palate  was  closed  with  a  plate,  his  speech  was  quite  as  imperfect  as  any 
patient  with  an  open  cleft.  The  correction  of  this  case  would  not  have  been  so 
successful  with  the  obturator  alone  or  without  the  preliminary  correction  of  his 
teeth,  the  expansion  of  the  arch,  and  the  insertion  of  the  bridge  denture  which  also 
corrected  a  decided  facial  deformity. 

A  finale  far  more  to  be  regretted  is  where  the  patient  is  left  with  a  complete 
surgically  closed  cleft,  but  with  the  velum-palati  so  inadequate  in  its  length  and 
possibilities  of  functional  action  that  it  leaves  a  wide  opening  at  the  oro-nasal 
passage,  and  consequently  the  speech  rarely  if  ever  is  improved.  Many  of  the  sur- 
gical operations  on  cleft  palate,  though  complete  crass  failures  in  the  restoration 


CHAPTER    VII.     IRREGULARITIES  AND  SURGICAL  FAILURES 


All 


of  speech,  when  considered  from  a  surgical  standpoint,  are  worthy  of  being  classed 
among  operations  of  the  very  highest  order,  demanding  a  degree  of  consummate 
skill  and  ingenuity  in  not  only  closing  extensive  clefts,  but  in  lengthening  the  soft 
palatal  tissues  in  a  manner  that  is  truly  wonderful.  In  the  more  skillful  and  ex- 
tensive operations  of  this  character,  when  performed  during  infancy,  vocal  articu- 
lation is  frequently  quite  perfect,  though  almost  invariably  lacking  in  normal  tone 
and  resonance;  the  speech  being  characterized  by  the  peculiar  nasal  or  "cleft 
palate  quality."  It  is  a  deplorable  fact,  however,  that  the  larger  number  of  sur- 
gical operations  of  today  are  of  a  lower  order,  and  that  there  are  so  many  cleft 

Fig.  43. 


The  above  illustration  shews  (1)  a  partial  siiryit-al  union:  (2)  Expansion  of  the  arch;  Kit  Restoration 
denture,  and  (4)  The  obturator  in  position. 

palate  operations  attempted  at  all  ages  and  upon  all  sizes  of  clefts,  often  with  no 
apparent  effort  or  expectation  of  doing  more  than  to  barely  unite  the  borders  of 
the  cleft.  These  supposedly  successful  cases  especially,  and  in  fact  all  cases  where 
the  clefts  have  been  completely  united  with  results  which  debar  the  patient  from 
acquiring  perfect  speech,  are  particularly  to  be  deplored,  because  it  is  rare  that 
persons  so  afflicted  or  their  friends  will  consent  to  the  destruction  of  an  operation 
which  has  been  attained  through  such  incalculable  hardships.  Nor  can  they 
be  assured,  under  the  circumstances,  that  the  usual  perfect  result  of  prosthetic 
treatment  will  be  attained. 

Fig.  44  was  made  from  the  models  of  a  man  over  twenty-five  years  of  age. 
It  will  serve  to  illustrate  the  not  uncommon  appearance  of  a  surgical  closure  of  a 
cleft.  The  distance  from  the  posterior  border  of  the  velum-palati  to  the  nearest 
extended  position  of  the  posterior  pharyngeal  wall  was  fully  three-fourths  of  an 
inch,  and  consequently  his  speech  had  all  the  imperfect  characteristics  of  open 


478  PANT   /.v.     T//E  PROSTHETIC  CORJiECTIOX   OE  CEEET   PA /.ATE 

cleft  palates.  Tlie  surgically  closed  cleft  was  opened  for  the  insertifjii  of  a  flexible 
velum;  and  wliile  the  result  was  far  from  perfect,  his  speech  and  voice-tone  were 
considerai^ly  improved.  This  was  Ix-fore  the  days  of  the  velum-obturator  which 
doubtless  would  have  been  far  more  successful. 

Fk;.  44. 


The  above  dental  casts  show  (1)  the  original  occlusion  of  the  front  teeth;  (li)  the  common  result  of  an  . 
imperfect  surgical  operation,  and  (3)  after  the  correction  of  the  teeth  preliminary  to  opening  the  cleft 
for  the  insertion  of  an  obturator. 

The  case  is  presented  here  principally  to  show  the  common  malocclusion  of 
the  teeth  in  connection  with  extensive  clefts  and  what  may  be  accomplished  in  their 
correction  at  quite  an  advanced  age. 

While  it  is  true  that  a  very  large  porportion  of  cleft  palate  patients  who  have 
received  unsatisfactory  surgical  treatment  are  unwilling  to  try  what  they  believe 
to  be  "another  experiment,"  especially  those  who  have  obtained  a  complete  and 
even  partial  closure  of  the  cleft,  it  happens  to  be  true  also  that  nearly  one-half  of 
the  many  patients  for  whom  the  author  has  inserted  artificial  palates,  have  at  some 
time  during  earlier  life — mostly  during  infancy — received  surgical  treatment  for 
the  correction  of  their  cleft  palates. 

Let  us  hope  that  the  proportion  of  surgical  failures  will  be  greatly  lessened 
in  the  future  by  the  general  resolve  that  must  come  to  all  well  informed  honest 
surgeons,  to  confine  their  future  operations  to  infants,  and  even  then  to  accept  only 
the  most  favorable  cases,  with  the  determination  to  follow  them  up  with  proper 
instrviction  for  the  acciuirement  of  speech.  Among  the  poorer  classes,  where  this 
deformity  seems  to  most  frequently  arise,  the  most  favorable  physically  disposed 
tissues  and  perfect  surgical  closure  of  the  clefts  of  infants  are  not  very  likley  to 
be  followed  at  the  proper  stage  of  development  by  the  parents  or  the  surgeon  with 
the  necessary  persistent  endeavor  toward  the  kind  of  training  that  will  teach  the 
child  to  commence  and  continue  the  articulation  of  the  oral  elements  in  proportion 
to  the  development  of  his  speech.  The  general  history  of  these  cases  is  that  the 
child  grows  up  speaking  about  the  same  as  he  would  have  done  without  an  operation. 
The  only  advantage,  therefore,  in  operations  for  the  closure  of  congenital  clefts 
under  these  circumstances  resolves  itself  into  a  temporary  display  of  surgical  skill 
for  a  few,  or  to  show  one  of  the  great  accomplishments  in  oral  surgery  before  an 


CHAPTER    VII.     IRREGULARITIES  AND  SURGICAL  FAILURES  479 

admiring  class.    This  is  particularly  tn.:e  if  the  patient  is  older  than  five  years,  and 
the  inexcusability  of  the  operation  increases  in  proportion  to  the  time  after  that  age. 

While  it  no  doubt  is  true  that  the  surgical  treatment  of  cleft  palate  for  children 
bom  of  wealthy  parents  could  meet  with  the  highest  degree  of  success,  because  of 
the  care  and  teaching  that  could  be  given,  still,  up  to  the  present  time,  because 
parents  and  even  surgeons  are  not  informed  in  regard  to  the  value  and  necessity 
of  early  speech  training,  the  results  in  these  cases  are  quite  as  likely  to  be  as  un- 
satisfactory as  others. 

This  failure  to  speak  perfectly  is  seen  on  every  hand  among  cleft  palate  children 
and  adults  in  all  social  degrees  of  life,  who  have  been  operated  upon  during  infancy. 
Even  among  the  wealthy  and  most  refined  people,  where  no  expense  has  been  spared 
in  the  procurement  of  the  most  prominent  surgeons  who  have  been  given  a  free 
hand  to  choose  the  time  arid  character  of  the  operation,  many  of  these  children 
go  through  life  greatly  handicapped  with. embarrassingly  imperfect  speech. 

It  is  hoped  that  the  time  is  not  far  distant  when  there  will  be  an  appreciation 
of  the  value  of  the  velum-obturator,  and  what  may  be  accomplished  in  proper 
speech  training. 


INDEX 


ABNORMALLY  enlarged  mandible,  317,  310,  322 
■^^     Abnormal  Interproxiniate  Spaces,  354 
Advanced  Principles  of  Technics,  155 
Alignment,  definition  of,  10 

arch-bows,  263,  332,  334,  355 
Alveolar  process  and  alveoli,  66 
Anchorages,  technics  and  principles  of,  118 

reciprocating     or     movable,     125,     see     "Inter- 
maxillary" 

rootwise,  122,  242,  252,  298,  314,  361 

stability  of,  120,  124 

stationary,  121,  286 

sustained,  123,  124,  315 
Ana:sthetics,  local,  354 
Angle's  bodily  movement,  114 

direct  intermaxillary  force,  368 

teaching,  80,  379 

wire  ligatures,  342 
Anterior,  definition  of,  12 
Apparatus,  important  requisites  of,  95 

alignment,  168,  331,  334 

assembling  and  fitting,  172,  211,  273,  see  Part  VII 

bodily  movement,  170,  173,  252,  271,  276,  298 

contracting  and  expanding,  see  "Expansion"' 

extruding  and  intruding,  283,  284 

midget,  1.59,  166,  168 

rotating,  340,  341,  342,  343 
Application  of  force,  see  "Force"  95,  109 
Arch-bows,  definition  of,  11 

alignment,  211,  263,  332,  334,  355 

arch  push  bow,  see  protruding  and  expanding 

contraction,  263,  267,  3.55 

expansion,  116,  337,  346,  347,  348 

labio-buccal,  267 

lingual,  349,  351 

lingual  yoke,  211 

lug.  206,  207,  208 

protruding  and  expanding,  206,  207,  209,  271 

protruding  contour  power,  170,  172,  271,  298 

midget,  168,  169,  170,  172 

resilient,  161,  166,  168,  169,  283,  331,  332,  334 

retruding,  263.  267,  355 

spring,  116,  349,  3.50 

torsional,  116 
Arch,  dental,  definition  of,  11 

club  or  saddle  shaped,  350 

contracted  and  expanded,  335,  346,  3.')0,  351 

expansion  of  lower,  334,  3.52,  353 

narrow,  116,  347,  349 


Arch,  normal,  61 

unilateral  contraction  of,  351 

V-shaped,  351 
Arrangement  of  teeth,  61 
Art,  5 


DANDS,  fitting  of,  1.55,  385,  387,  388 

band  material,  148,  150 

construction  of,  147,  171,  see  "Incisor  bands" 

finishing  and  plating,  162 

measurements  of  partially  erupted  cuspids,  151 

midget,  159 

soldering  of,  151 

pluggcr,  1.57 
Bars, 

lug  pull,  242,  314,  355,  361 

lug  push,  206,  207,  208,  252,  335 

pull  or  traction,  263,  264,  341,  394 

push,  208,  212,  314,  3.36,  341 

resilient,  107 

ribbon,  341 
Basic  Principles  of  Practice,  61 
Batteries,  163 
Bicuspid,  see  "Premolar" 
Bilateral,  definition  of,  14 

maleruption  of  cuspids,  200,  209,  215 
Bimaxillary  supra  and  infra-occlusion,  definition  of,  10 
Bimaxillary  Protrusion  and  Retrusion,  232,  233,  241 
Biology,  laws  of,  37 

heredity,  38 

natural  selection,  40 

natural  variation,  39 

environment.  40 
Black,  14,  61 
Blowpipe,  1.52.  1.59 

Bodily  expansion,  116,  347,  349,  see  "Expansion  " 
Bodily  movement,  principles  of,  109 

buccal,  347,  349 

disto-mesial  or  lateral,  242,  252,  314,  361 

labial  or  protruding,  170,  173,  252,  271,  298,  303 

lingual  or  retruding,  276 
Bodily  protrusion  of  upper  denture,  266 
Bodily  retrusion  of  upper  denture,  295 
Bodily  working  retainer,  175,  176,  399 
Bows,  see  "Arch-bows" 
Bracket  and  hook,  162 

Buccal,  definition  of,    13,   see  "Bodily  movements" 
Broomell,  69 


481 


482 


INDEX 


/^ANINE  and  cusijid,  ilcfinitioii  of,  11 

^^     Casts,  dental  and  facial.  !:«t,  1  1 1 .  1  H'.  !  10 

Causes,  see  "Etiology" 

Chin  retractors  or  caps,  see  "Occipital  Force"  133,  135 

Chin,  importance  of  in  diagnosis,  .54,  76,  183,  192,  234 

retruded,  279 
Class     I  Normal  disto-mesial  occlusion  of  the  buccal 

teeth.  199 
Class    II  Distal  malocclusion  of  lower  buccal  teeth,  24.5 
Class  III  Mesial  malocclusion  of  lower  buccal  teeth.  290 
Classes,  dento-facial  malocclusions,  ISO 
Classes,  table  of,  19 
Cleft  palate,  prosthetic  correction  of,  409 

impressions,  437,  439,  441,  444 

trial-model,  4.50 

working-model,  448 

flask,  4,57 

plaster  models,  4.59 

investment  models,  4fH.  4ti4 

metal  casts,  467 

packing,  vulcanizing,  and  finishing  obturator,  469 

complications    with    irregularities    and    surgical 
failures,  471,  see  "Speech" 
Close-bite  malocclusion,  definition  of.  10 
Close-bite  malocclusion,  283,  287 

Closing  of  abnormal  spaces,  242,  3.54,  3.56,  3.57,  358,  see 
"  Bodily  disto-mesial  movements  " 

molar  spaces,  .359,  361  ',  i  ■' 

Concomitant  characters  of  Class  II,  279 
Construction  of  Bands,  see  "Bands" 

midget  appliances,  1.59 
Contour  apparatus,  see  "  Bodily  Movement  Apparatus" 
Contrude,  definition  of,  13 
Coronal  zones,  1.56,  186 
Coronal  protrusions,  upper,  262.  27(J 
Crowded  malalignments,  333,  357 
Crowns  for  opening  bite,  284.  285 
Counter-sunk  nuts,  175 
Cryer,  68,  81,  261,  318,  .362.  365 
Cushing,  305 

Cuspid  bands  for  retaining  appliances,  3S7 
Cuspids,  bodily  movement  of,  242,  314 

bilateral  maleruption  of,  209,  215 

impaction  of,  364,  367,  369,  371 

maleruption  of,  200,  205,  208 

rotation  of,  341,  342 

unilateral  maleruption  of,  205 

"T^ARWIN,  40,  51 

Deciduous  teeth, 

importance  of  preserving,  30 

premature  loss  of,  30 
Dental  Orthopedia,  definition  of,  3 
Dento-facial  malocclusions.  Part  VI 

dento-facial  area,  definition  of,  9,  183,  1S5,  186 

observation  training,  192 

practical  diagnosis,  193 

principles  of  diagnosis,  181,  190 

zones  of  movement,  186 


Diagnosis,  principles  according  to  Classes,  195 
IMrcct  and  disto-mesial  intermaxillary  force,  see  "  Inter- 
maxillary Force" 
Distal  and  mesial,  definition  of,  11 
Dome,  definition  of,  11 

"pLASTIC  Ijands,  see  "Occipital  and  Intermaxilliary 

Force 
Elliptical  tul)ing,  212,  336.  3.52,  399 
Environment,  40 
Etiology,  23 

biological  laws,  influences  of,  37 

causes  in  relation  to  treatment,  26 

comparison  of  childhood  and  adult  physiognomies, 
35 

compound  causes,  24 

influences  of  deciduous  dentures.  30,  33 

influences  of  heredity,  see  "Heredity" 

maleruption  of  labial  teeth,  32 

thumbsucking,  33 

unknowable  causes,  23 
Expansion    and    contraction    of    dental    arches,    see 

"Arches" 
Expansion  and  contraction 

bodily,  116,  347,  .349 

disto-mesial,  207 

jacks,  3.50,  351 

lateral,  346,  .3.53 

lingual  arch,  351 

of  premolar  area,  347,  349,  352 

spring,  347,  349 

torsional,  116,  see  "Force" 
Extraction, 

considered  by  Dr.  Cryer,  73 

importance  of,  79,  380 

in  bimaxillary  protrusion,  88,  ,S9,  2.36,  2.39,  240 

iniudicious,  of  permanent  teeth.  83,  84,  294 

in  maleruption  of  cuspids,  84,  85,  90 

in  mesial  malocclusion  of  upper.  127,  128 

in  protrusion  of  upper  with  lower  normal,  188,  269 
in  protmsion  of  upper  with  retrusion  of  lower, 
197,260 

in  protrusion  of  upper  apical  zone,  274 

judicious,  of  permanent  teeth,  83,  87 

of  deciduous  teeth,  30 

rules  of,  83 
Extruding  and  intruding  apparatus,  283,  284 
Extrusive  and  intrusive,  definition  of,  13 

apparatus,  283,  284 

force,  108 

T7ACIAL  impressions  and  casts,  141,  142,  146 

Facial  outlines  in  diagnosis,  190 
Farrar,  80,  95,  306,  3.58 
Finger  spurs,  160,  161 
Fitting  and  assembling  apparatus,  172,   see   "Primary 

Principles"  in  Parts  IV  and  V. 
Flask,  cleft  palate,  457 
Force,  principles  of,  95,  109 


INDEX 


483 


Force,  elastic,  126,  225,  343 

expanding,  347,  351,  see  "Expansion" 

intermaxillary,  see  "Intermaxillary  Force" 

laws  of,  112,  US 

linguo-buccal,  132,  225,  286 

misapplication  of,  104 

occipital,  126,  132 

reciprocating,  340,  see  "Intermaxillary  Force" 

rootwise,  347,  see  "Anchorages" 

screw,  95,  96 

spring,  107 

torsional,  116,  166,  170,  348 
Frenum,  treatment  of  abnormal,  354,  355 

r^  ENERAL  Bimaxillary  Supra-  and  Infra-occlusion, 

^       definition  of,  10 

German  silver,  see  "Nickel  Silver" 

Gingival,  definition  of,  13 

Gold  and  platinum  bands  for  appliances,  384,  385,  387 

plating  solution,  163 

soldering,  151,  160 

wires  and  arch-bows,  169,  171,  398,  400 
Goslee,  321,  325 
Gray,  177,  185,  318 

Grinding  teeth   in   the  correction  of  open-bite   mal- 
occlusion, 231 

TTABIT  of  mouth-breathing,  227,  229,  230 

Harmony,  dento-facial,  182 
Headgear,  see  "Occipital  apparatus,"  133 
Heredity,  38,  43,  378 

ethnologically  considered,  43 

influences  of,  upon  deciduous  dentures,  33 

law  of,  38 

Mendel's  I.aw,  39,  44 

principles  of,  53 
Hook  and  bracket,  162 
Huxley,  51 

Hygienic  requirements,  165 
Hypertrophied  gums,  76 

T  M FACTE D  teeth,  362 

Angle's  method  of  treatment,  368 

general  treatment,  366 

lower  third  molars,  363,  364 

second  premolars,  369 

upper  central  incisors,  371,  372,  373 

upper  cuspids,  364,  367,  369,  371 
Impressions  and  casts, 

dental  and  facial,  139,  141 

of  cleft  palate,  437 
Impression  trays,  140 

anchorage,  121 

occlusal,  141 
Incisors, 

bands  for,  148,  155 

bodily  movement  of,  103,  109,  111,  170 

inclination  movement  of,  97 


Incisors,  inlocked,  337,  338 

impacted,  371,  372,  373 

intrusive  and  extrusive  movement  of,  2.30,  231, 
283,  284,  286 

protruding  movement  of,  HI,  170,  2.52,  257,  298 

retruding  movement  of,  103,  263,  264,  267,  276 

rotation  of,  340,  341 
Incisive  or  intermaxillary  bone  (Gray),  185 
Inclination,  of  teeth.  Black's  definition  of,  64 

movement,  96,  97 
Inferior,  definition  of,  13 

Influences  of  heredity  upon  deciduous  dentures,  33 
Infra-occlusion,  definition  of,  10 

bimaxillary,  287 

of  cuspids,  331,  367,  368 

of  incisors,  2.30,  231,3.32 
Iniudicious  extraction,  84,  .86.  294 
Instruction  in  speech,  409,  420,  see  "Speech" 
Interdigitate,  definition  of,  10 
Intermaxillary  force,  principles  of,  126 

apparatus,  213,  2.52,  257,  267.  268,  286,  394 

bucco-lingual,  132,  286 

direct  or  extrusive,  132,  209,  211,  230.  286,  368 

disto-mesial,  213,  231 

for  extensive  movements,  257 

lateral,  225 

linguo-buccal,  132,  225,  286 

span  hooks,  129,  268 

tube  hooks,  129,  257,  267 

tube  Ts,  230,  343.  3.58,  397 
Interproximate  spaces,  354,  356 

between  lower  front  teeth,  354,  356 

between  buccal  teeth,  359,  361 
Introduction  of  band  material,  14,8,  150 

impression  trays,  140 

waxed  tape,  147 
Intrusive  and  extrusive,  definition  of,  13 

apparatus,  283,  284, 

force,  108 
Irregularities,  definition  of,  8 

caused  by    injudicious  extraction  of   permanent 
teeth,  84,  86,  294 

resulting  from  loss  of  deciduous  teetli,  30 

T  ACKSCREWS, 
J      arc,  352 

bar  rest,  208,  335,  336,  351,  352 

drop,  336,  350 

elliptical  spur  rest,  334 

expanding,  207,  334,  351,  352,  353 

fork  end,  208,  336,  341 

pin  rest,  3.34 
Jackscrews,  reciprocating,  340,  341 

turnbuckle  expansion  and  contraction,  353 
Judicious,  or  rational  extraction,  principles  of,  87 
Jumping  the  bite,  280 


K 


INGSLEY,  80,  378,  379 


484 


INDEX 


TAHIAI.,  ik-finition  of.  13 

Laliio-mental  curve,  definition  of,  9 
Lateral  expansion  and  eontraction,  346,  353 
Lateral  incisors  inlocked,  335,  336,  337 
Lateral  malocclusion,  220 
Lateral  movement  of  cuspids,  353 
Laws  of  Biology,  37 
Law  of  Force,  112,  118 
Law  of  Levers,  97 
Law  of  Heredity,  38 
Levers.  97 

Lever  rotator,  107,  339,  340 
I  igatures,  rubber,  335,  343 

silk,  343,  344 

wire,  3.37,  342 
Lingual,  definition  of,  13 
Lock-nuts,  172,  29S.  399 
Lug  nut  attachment.  207,  335 
Lower  protrusions,  312 

prognathism,  317 

retrusions,  219,  252,  255,  279,  283 

TVTAKUEN,  410 

Malalignment,  definition  of,  10 
Malalignments  and  crowded  complications,  333 
Maleruption  of  cuspids,  see  "Cuspids" 

of  labial  teeth,  32 
Mallet,  lead,  158 
Malocclusion,  definition  of,  10 

bimaxillar>  short-bite,  287 

close-bite.  283 

dento-facial,  181 

etiology  of,  23 

mesial,  of  lower  buccal  teeth,  291 

open-bite,  227,  317 

unclassified,  327,  see  Part  VII 
Malposed,  definition  of,  10 
Malturned,  definition  of,  12 
Maltiu-ned  teeth,  339 

Mandible,  abnormally  enlarged,  317,  319,  322 
Matteson,  337 
Measurements,  partially  erupted  cuspids,  151 

taking  of,  148,  156 
Mechanics,  principles  of,  6,  95 
Mechanism  of  speech,  409 
Mendel's  Law,  39,  44 
Mesial  and  distal,  definition  of,  11 
Mesial  malocclusion  of  lower  buccal  teeth,  291 
Methods  of,  closing  abnormal  buccal  spaces,  242.  361 

closing  labial  spaces,  354,  357 

cutting  cuspid  retainer  bands,  387 

drilling  holes  for  staple  retainer,  402,  403 

introducing  tape,  147 

opening  space,  335 

restoring  broken  interproximate  extensions,  391 
Midget  apparatus,  159,  166,  168 
Modeling  compound,  140 
Molar,  anchorage,  120,  124 

bands,  1.50 


Molar,  bodily  movement  of.  361,  see  "Root  wise  Anchor- 
ages" 

crowns,  284,  285 

impactions,  363,  364 

measurements,  1.50 
Mouth-breathing  habit,  227,  229,  230 
Movements,  primary,  96 

bodily,  96,  103,  109,  .3.59 

extrusive  or  intrusive,  96,  108 

inclination,  96 

lateral.  98 

protrusive  or  retrusive.  111,  127 

rotating,  96,  106 
Murphy,  Dr.  J.  B.,  412 

■\T  ARROW  and  wide  arches,  334,  346 
Naso-labial  folds,  definition  of.  9 
Natural  selection.  40 
Natural  variation,  39 
Negro  and  Caucasian  skulls,  74 
Newton,  118 
Nickel  silver.  164 
Nomenclature,  8 

Normal  and  anatomic,  definition  of,  9 
Normal  occlusion,  61,  see  "Arrangement  of  Teeth" 
Nut,  counter-sunk,  175 
lock,  172,  298.  399 

r^BSERVATION  training.  192 

^-^       Obturator,  411,  438,  455,  470,  475,  477 

Occipital  apparatus,  133,  213,  286 

dental  movement  of  buccal  teeth,  213 

extruding  lower,  231 

force,  principles  of,  126 
Occlusion,  definition  of,  9 

influences   which   characterize,   see   "Etiology  of 
Malocclusion  " 

principles  of,  78 

relations  of,  78 

typical  and  atypical,  68 
Occlusal  plane,  definition  of,  10,  12 
Odontomata,  24,  362,  366,  372 
Open-bite  malocclusion,  173,  227,  317 

causes  of.  229 

definition  of.  10 

grinding  of  teeth  in  correction  of,  231 

treatment,  230 
Oral  element,  14,  424 

Origin,  use  and  misuse  of  intermaxillary  force,  126 
Oro-nasal,  definition  of,  14 
Orthodontia,  definition  of,  3,  8 
Orthodontic  principles  of  diagnosis,  181 
Orthopedia,  definition  of,  3,  9 
Osborn,  47 

PACKING  and  finishing  the  obturator,  469 

Part  I  Preliminary  Principles  of  Practice,  3 
Part    II  Etiology  of  Malocclusion,  23 
Part  III  Basic  Principles  of  Practice.  61 


INDEX 


485 


Part     IV  Tcchnic  Principles  of  Practice,  95 
Part       V  Primary  Principles  of  Practice,  139 
Part     VI  Practical  Treatment  of  Dento-Facial  Mal- 
occlusions, 181 
Part    VII  Practical  Treatment  of    Unclassified   Mal- 
occlusions, 327 
Part  VIII  Principles  and  Technics  of  Retention,  377 
Part     IX  The  Prosthetic  Correction  of  Cleft  Palate, 

409 
Pericementitis  caused  by  movements,  300 
Pericemental  membrane,  injury  from  wire  ligatures,  342 
Physiognomies,  3.5 
Pierce,  365 

Placing  bands,  157,  see  "Bands" 
Plaster  casts  and  impressions,  139,  141,  14(5 
Plates,  346 

Coffin,  346 
Plating  apparatus,  163 

of  bands,  162 

solution,  163 
Platinum-gold,  163,  164,  172,  384,  385 

wires,  169,  171,  .398,  400 
Pliers,  band,  149,  150 

band  removing,  158 

band  slitting,  1.58 

bending,  299,  353 

burnishing,  151 

contouring,  156 

crown  removing,  285 

retainer,  removing,  391 

rootwise,  172,  300 

solder,  151 

step,  162 

tape,  148 
Plugger,  band,  157,  388,  390 
Plumbago,  as  luting,  151,  388 
Posed,  definition  of,  10 
Premolar,  definition  of,  14 

extraction  of,  83,  202.  215,  216,  263 

impaction  of,  369 

movable  attachment,  209,  211 

rotation  of,  341 
Primary  principles  and  technics,  147 
Primary  principles  of  practice,  139 
Principles  of  dental  anchorages,  118 

diagnosis  and  treatment,  181,  193,  195 

force,  96 

intermaxillary  and  occipital  force,  126 

mechanics,  95 

occlusion,  78 

practice,  3,  61,  93,  1,39 
Principles  of  retention,  375,  377 
Prognathic  appearance  (Cryer),  76,  317 

jaws,  312,  317,  318,  319 
Prosthetic  correction  of  cleft  palate,  409 
Protrude,  definition  of,  12 
Protruding  contour  apparatus.  170,  252,  271,  298,  303 

fitting  of.  172,  273,  298,  .300 
Protrusions,  bimaxillarv,  2.32,  2.33,  241 


Protrusions,  inherited,  197,  2S0 

locally  caused,  35,  190,  218 

of  lower  denture,  313,  315 

of  upper,  197,  247,  see  Div.  2,  Class  II 

of  upper  apical,  274,  275 

of  upper  bodily,  266.  269 

of  upper  coronal.  262,  270 

of  mandible  292,  322 
Pyorrhea,  cause  of  irregularities,  356,  357 

QUESTION  of  extraction,  83 
injudicious,  of  permanent  teeth,  83,  84,  294 
judicious,  or  rational,  of  permanent  teeth,  87 
rules  of,  83 

■D  ADIOGR.A.MS,  24,  310,  362 

Reactive  force,  118 
Receding  chin,  232,  234,  235,  236,  239,  240 
Reciprocating  or  movable  anchorage,  125 
Reinforcements,  116,  348,  350 
Relation  of  coronal  zones,  156,  186 
Removal  of  bands,  158 

of  crowns,  285 

of  retainers,  391 
Resilient  arch-bows,  161,  166,  331,  346 
Retaining  fixtures,  384,  399 

attachments,  393 

bodily  movements,  398,  .399,  400 

construction  technics,  385,  386 

die  for  swaging  clips,  3.89 

direct  and  occipital,  .397,  398 

four  band,  385 

intermaxillary,  394 

intermaxillary  anchorage  methods,  395 

lateral  expansions,  393 

permanent,  401,  402 

placing  the  appliance,  390 

removal,  391 

restoring  broken  extensions,  391 

retruded  movements,  .394 

six  band,  386 
Retention,  principles  of,  377 

imperative  demands  of,  383 

importance  of  bodily,  381 

importance  of  extraction,  380 

importance  of  interdigitating  cusps,  380 

influences  of  heredity,  378 

local  influences,  379 

occlusal  influences,  379 
Retractors,  chin,  133 
Retrude,  definition  of,  12 
Retruding  contour  apparatus,  276 
Retrusion, 

bimaxillary,  232,  242 

inherited,  249    Division  1,  Class  II 

lower  denture,  249,  2.50,  251,  2.53 

mandible,  236,  238 

mandible  and  lower  denture,  279,  280 

upper  apical,  270,  271 


486 


INDEX 


Rctnisiim.  iipjicr  I)oilily,  'iOo,  297,  see  Class  III 

iijipcr  coronal,  '11  \ 
Ribbon  bars  and  jacks,  .341 

Rise  ami  development  of  intermaxillary  force,  126 
Robinson,  i:51,  :«jS 
Rootwise,  definition  of,  13 

anchorages,  122,  242,  2,52,  276,  298,  314,  347,  301 

bars  and  extensions,  122,  347,  357 
Rotate,  definition  of,  12 
Rotating  movement,  96,  106,  344 

of  cuspids,  .341,  342 

of  incisors,  340,  341 

of  premolars,  341 

with  finger  spurs,  101 

with  levers,  107,  339,  340 

with  elastics,  343 

with  silk,  343,  344 

with  wire,  .339,  342 

CALISBURY,  414 

Science,  .5 
Scissors,  curved,  1.5.5 

tape,  148 
Scope  of  dento-facial  field,  1S4 
Scope  of  Dental  Orthopedia,  3 
Screw  force,  95,  96 
Separating  tape,  147 
Short-bite  malocclusion,  287 
Silk  elastics,  134 

ligatures  for  rotating,  343,  344 
Silver,  nickel,  164 
Skiagraphs,  see  "Radiograms" 
Sliding  tubes,  131,  213,  2.57,  268 
SUtting  of  bands,  1.5S 
Solder,  gold,  149,  153,  1.55,  160,  164 

silver,  154 

soft,  211 
Solder  pliers,  151 
Soldering  of  attachments,  152,  159 

bands,  151,  1.52 
Spaces,  abnormal  intcrproximate,  3.54 

closing  of  buccal,  see  "Rootwise  Anchorages" 

closing  of  incisor,  355,  357,  359 
Span,  intermaxillary,  129,  268 
Speech,  mechanism  of,  409,  421 

aspirates,  433,  434 

classification  consonant  oral  elements,  428 

explosives,  431,  435 

methods  of  instruction,  415 
Speech,  nasals,  429 

oral  elements,  424 

sound  images,  414 

vowels  and  consonants,  426,  427 
Spring  arch  contractor  and  expander,  see  "Expansion" 

lever  rotator,  107,  339,  340 
Stability  of  anchorage,  120 
Stackpole,  56 
Staple  retainer,  402 
Stationary  anchorages,  121,  123,  175,  286 


k^ 


Superior,  definition  of,  13 
Suitplcmentary  retainers.  .393 
Su])ernumerary  teeth,  362,  366 
Supra-oeclusion,  definition  of,  10 
Surgical  failures,  471 
Sustained  anchorages,  123,  31.5 

"Y  ATTACHMENTS  for  elastics,  176,  230,  313,  3.58 
■*■  397 

premolar  attachments.  206 
Table  of  classes,  19 

of  characters,  328 
Taggart,  388 
Tape,  waxed,  147 

method  of  introducing,  147 

scissors,  148 

sizes  of,  147 
Teaching,  principles  of,  3,  410 
Technics  of  dental  anchorage,  118 

of  attachments,  170 

of  band  fitting,  155,  156 
Thumbsucking  protrusions,  .33,  218 
Torsional  force,  116,  166,  170,  .348 
Tooth  levers,  101 
Traction  bars,  see  "  Bars" 
Training,  observation,  192 
Trays,  impression,  121,  140,  141 
Trimming  of  casts,  141 
Trudo,  definition  of,  12 
Tubing,  elliptical,  212,  .336,  .352.  399 

open,  129,  211.  278.  298,  .399 

U,  160,  170,  174,  176,  298 
Tying  of  ligatures.  344 
Types,  table  of  in  Class  I,  199 

in  Class  II,  245 
Typical  and  atypical  occlusion  of  the  teeth,  68 

T  TXCLASSIFIED  malocclusions.  .329 
^      Unilateral,  definition  of,  14 
maleruption  of  cuspids,  205 
Unimaxillary,  definition  of,  14 

■yELUM-OBTURATDR,  411,438,4.55,470,  475,  477 

*  palati,  422 

V-shaped  arches,  351 

VyALLACE,  51 

Working  retainer,  175,  176,  400 


X 
Y 


RAY,  24,  310,  362 


OKEbow,  lingual,  211 
Younger,  343 

'ONES,  definition  of,  11 

'   dento-facial,  see  "Diagnosis"  Chapter  XXI 

of  movement,  186 

relation  of  coronal,  156,  186 


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